Psychological Distress and Perceived Stress Outcomes of Anxieties Related to COVID-19 and Russia’s Attack on Ukraine

Abstract In recent years, European societies have been faced with an enormous challenge when the ongoing struggle of the COVID-19 pandemic coincided with the biggest military conflict in the region since World War II, namely Russia’s full-scale attack on Ukraine. As such crises can have a substantial impact on mental health, it is crucial to follow their effect on the population, especially in the circumstances of multiple coexisting threats. Two studies examined the association of COVID-19 anxiety and war-related anxiety with mental health in Finnish population. We found that COVID-19 anxiety and anxiety over Russia’s attack on Ukraine were associated with psychological distress and perceived stress. Moreover, we found an interaction effect on psychological distress consistently in two samples, showing that participants who reported higher COVID-19 and war-related anxiety experienced higher psychological distress. These results show the especially heavy burden that these serious coinciding crises have on the mental health of the population. The findings of the current study provide directions for future research and have implications for practitioners and decision makers alike.


Introduction
In recent years European societies have been subjected to unusual and challenging circumstances as two major sources of stress overlapped.The ongoing COVID-19 pandemic was followed by the major escalation of the continuing Russo-Ukrainian war as Russia launched a full-scale attack on Ukraine in February 2022 (United Nations, 2022), leading to a difficult and uncertain situation in the region (European Investment Bank, 2022;International Crisis Group, 2022).Such crises can result in an affective response and state of anxiety (Fancourt et al., 2021;Miller & Rasmussen, 2010;Robinson et al., 2022;Savolainen et al., 2021).Specifically, this unusual case of a prolonged COVID-19 crisis overlapping with a sudden escalation of war raises a concern about the source of anxiety in the population.With the media attention switching to the Russo-Ukrainian war, it is possible COVID-19 anxiety decreased and got largely replaced by warrelated anxiety, but it is also conceivable that both accumulated, potentially creating acute risks for mental health in the population.It is crucial to follow the occurrence and consequences of such crisis-related anxiety so that it can be understood and addressed appropriately.

Anxiety and psychological distress
State anxiety is defined as an emotional state involving worried thoughts, feelings of tension, nervousness, and physiological symptoms such as dizziness or increased heart rate.It is a future-oriented, broad response to a diffuse threat.It differs from trait anxiety which is defined as the individual's stable predisposition for experiencing anxiety (American Psychological Association, 2022;Spielberger, 1979).Although anxiety is understood as a healthy response to stress, in certain contexts, such as major crises, prolonged anxiety in particular can have various negative health outcomes, impacting both individuals and whole communities (Tuma & Maser, 2019).
Psychological distress refers to a state of decreased mental well-being, which manifests through various psychological (e.g., depression symptoms), somatic (e.g., headaches, sleep troubles), behavioral (e.g., irritability, anger issues) and functional problems (e.g., lowered concentration; Drapeau et al., 2012).Perceived stress relates to the subjective evaluation of the burdening effect of a potentially stressful situation (Cohen et al., 1983).It has been deemed crucial in evaluating the effects of stressful situations on individuals, as it is the subjective appraisal of the circumstances that guides individual's coping efforts (Cohen et al., 1983;Lazarus & Folkman, 1984).Various factors, including sociodemographic characteristics and financial security can alter this appraisal and, subsequently, the impact of the stressful situation on the individual (Bonanno et al., 2007;Neria et al., 2008).Psychological distress and perceived stress are associated with subsequent further mental and physical health issues (Bovier et al., 2004;Rai et al., 2012).Therefore, it is important to investigate their occurrence and causes, especially in the context of prolonged crises.

Effects of the COVID-19 pandemic on individuals' wellbeing
The COVID-19 pandemic has significantly changed the lives of people worldwide, for instance, by impacting the world economy and altering social habits of people (e.g., Gupta et al., 2022;Toro-Alzate et al., 2021).In the beginning of the pandemic in 2020, individuals experienced acute anxiety largely related to the fear of the unknown, contagion and death of self or family members (Coelho et al., 2020;Fullana et al., 2020;Menzies & Menzies, 2020;Wang et al., 2020).As the pandemic persisted for three years, studies have reported that pandemic related anxiety has plateaued which could be due to habituation to the presence of the pandemic (de Abreu Costa et al., 2022).However, COVID-19 was still inducing fear and anxiety across different populations in 2022.For instance, the emergence of new variants of the coronavirus was associated with increased anxiety (Awijen et al., 2022;McNeil & Purdon, 2022) whereas arrival of the vaccine induced feelings of fear and distrust (Awijen et al., 2022).
COVID-19 can have long-term mental health consequences for individuals due to economic, social, and personal loss (Mueller et al., 2022;Piltch-Loeb et al., 2021).Increases in unemployment, income uncertainty and overall economic challenges and employment pressure have been observed together with worry, fear, and more severe stress, as well as in anxiety and depression symptoms that can affect individuals' protective and resistive coping behaviors (Lu & Lin, 2021).Both COVID-19 related health anxiety and economic anxiety are predictors of psychological distress, but economic anxiety has become more salient with the prolonged COVID-19 crisis (Timming et al., 2021).Indeed, the economic disruption has been associated with higher levels of psychological distress compared to COVID-19 exposure (Mueller et al., 2022).Thus, the mental health consequences of the pandemic stem from various factors related to the crisis and are more extensive than just related to the infection itself.

Effects of Russia's full-scale invasion of Ukraine on individuals' wellbeing
Wars, in general, not only have an impact on the directly involved individuals, i.e., the military personnel and refugees, but also affect the civilian people that are exposed to war news in the media or are in contact with the refugees (Rozanov, 2019;Surzykiewicz et al., 2022).Direct involvement in a war can be a risk for post-traumatic stress disorder (PTSD), depression, anxiety (Kurapov et al., 2023;Rozanov, 2019), and provoke other social and societal problems such as drug and alcohol misuse (Sheather, 2022).In addition to direct contact and exposure to war, war-induced mental health problems of civilians include anxiety, PTSD, depression and psychosocial dysfunctioning, among other things (Rozanov, 2019).Past research shows that being exposed to negative images in the media can have negative mental health consequences for the witnesses (Garfin et al., 2018;Johnston & Davey, 1997;Silver et al., 2013).Neighboring populations also suffer serious consequences of military conflicts (Yesilyurt & Elhorst, 2017), potentially leading to adverse mental health consequences.
In Finland, Russia's full-scale attack on Ukraine that began on 24 February 2022 evoked discussion and comparisons to the 1939-1940Finnish Winter War (YLE, 2022a).In the Winter War and the later 1941-1944 Continuation War, Finland defended its independence against the Soviet Union, despite suffering territorial and economical losses (Kivim€ aki, 2012).Because of the war over 400 000 people were evacuated from the Karelia region and Finland lost one of its biggest cities, Vyborg.The story of war and Finland's defense have remained an important source of national identity and pride (Kivim€ aki, 2012).Russia's full-scale attack on Ukraine understandably raised interest in Finnish history both domestically and internationally (YLE, 2022a).The feeling of a shared struggle, alongside the geopolitical situation of Finland sharing the longest land border (1340 km) with the Russian Federation in Europe, had also direct implications to Finnish society.Despite having strong ties to the North Atlantic Treaty Organization (NATO), Finland previously remained non-allied.Russia's full-scale attack on Ukraine has changed the situation and prompted a major change in the way Finnish society understands its position in the region, with public support of joining NATO increasing to record-high in the previously skeptical Finnish population (YLE, 2022b).This ultimately led to Finland, together with neighboring Sweden, applying for NATO membership in May 2022 (YLE, 2022c).
Although no studies to date have investigated the impact of Russia's fullscale attack on Ukraine in the Finnish context, research conducted so far points toward high emotional involvement of residents of various European and NATO member countries in the conflict, including experiencing anxiety, anger, perceived threat, and empathy toward the Ukrainian people (Moshagen & Hilbig, 2022).This is especially true for countries geographically close to the conflict, like Poland (Moshagen & Hilbig, 2022).Such emotional involvement can have adverse mental health consequences for individuals.For instance, a study among university students in Czechia found that feeling concerned about the Russo-Ukrainian war was positively associated with anxiety and depression symptoms (Riad et al., 2022).A survey among the general population in Germany found elevated levels of anxiety and depression symptoms during the first weeks of the full-scale invasion (Gottschick et al., 2022).Interestingly, those mental health issues were more severe than during the period of strictest COVID-19 restrictions in Germany.Participants reported also experiencing more intense fear of the impact of the Russo-Ukrainian war than other fears, including that related to the COVID-19 crisis.Strong fear of the impact of the war was associated with higher anxiety and depression symptoms, and higher stress and psychological distress (Gottschick et al., 2022).

The current research
Based on the past research and literature on these topics (Fancourt et al., 2021;Gottschick et al., 2022;Mueller et al., 2022;Piltch-Loeb et al., 2021), we conducted two studies investigating the impact of COVID-19 anxiety and anxiety over the Russo-Ukrainian war on mental well-being, namely psychological distress, and perceived stress in Finnish population.We expected the following: H1: Anxiety over the Russo-Ukrainian war is stronger than COVID-19 anxiety.
H3: Anxiety over the Russo-Ukrainian war is associated with higher psychological distress.
H4: Combined anxiety over COVID-19 and the Russo-Ukrainian war is associated with higher psychological distress.
H6: Anxiety over the Russo-Ukrainian war is associated with higher perceived stress.H7: Combined anxiety over COVID-19 and the Russo-Ukrainian war is associated with higher perceived stress.

Study 1
The purpose of Study 1 was to investigate anxiety over the Russo-Ukrainian war and COVID-19 anxiety among the Finnish working population.It was expected that people experience higher war-related anxiety than COVID-19 anxiety (H1).Moreover, we expected an effect of COVID-19 anxiety (H2) and anxiety over the Russo-Ukrainian war (H3), as well as their combined effect on higher psychological distress (H4).

Participants and procedure
For the first study, we utilized seven waves of the Social Media at Work in Finland survey data from 2019 to 2022.The survey was designed to represent the Finnish working population.Surveys were collected every six months, starting in March 2019, and totaling in seven time points (T1: N ¼ 1817; T2: n ¼ 1308, T3: n ¼ 1082; T4: n ¼ 1152, T5: n ¼ 1018, T6: n ¼ 982, T7: n ¼ 932).Our data collection at T7 began on 15th March 2022, less than three weeks after Russia started its full-scale attack on Ukraine, and ended on 24th April 2022.Participants were recruited by a data provider company, Norstat, utilizing their online research panels for recruiting participants via diverse offline and online sources.Participants did not receive direct financial compensation, but they can reclaim rewards with points they received from participating in surveys.Response rate at T1 was 28.3%.Invitations were later sent to original T1 participants, but T3 survey was only targeted to those who had taken part at T2.In this study the focus was on data from T4-T7 (collected autumn 2020 -spring 2022) that included measures on COVID-19 anxiety.Out of the original survey, the last T7 survey had a response rate of 51.29%.In total, 741 participants took part in the T4-T7 time points (40.78% out of T1 participants).
Comparison of sample characteristics with official statistics of Finland found no major bias in terms of gender, age, education level, and area (Official Statistics of Finland, 2022a, Official Statistics of Finland, 2022b;Oksanen et al., 2020).Nonresponse analysis shows that there is no major bias due to drop out, but drop out is more prevalent among young participants.Participants were working aged individuals, working in diverse occupational fields and 44.96% of them were female and 47.32% had obtained at least a bachelor's degree.Mean age of participants at T1 was 44.34 years and 39.01 years among dropouts.Table 1 shows the descriptive statistics of T7 participants.
The research protocol was reviewed by the Academic Ethics Committee of the Tampere region who concluded that the research did not contain any ethical issues.Participation in the study was voluntary.Participants were informed of the survey's objectives and assured that they could withdraw from the study at any point without providing any further reasoning.The survey was designed by the research group and collected in collaboration with Norstat.We conducted data integrity and quality checks after each data collection phase following the research group's protocol.

Psychological distress
We used the 12-item General Health Questionnaire to measure psychological distress (Goldberg et al., 1997).It is a commonly used, wellestablished measure for assessing well-being (Gnambs & Staufenbiel, 2018).
Likert scoring (0-3) was applied for each item, resulting in a scale ranging from 0 to 36.Internal consistency of the scale was excellent (x ¼ .92).

COVID-19 anxiety
The short version of the Spielberger State-Trait Anxiety Inventory (Marteau & Bekker, 1992) was adapted for the purpose of this study to measure state anxiety related to the COVID-19 crisis.Participants were asked: "What kind of reactions does the COVID-19 crisis evoke in you?Please rate how the following statements describe your state of mind right now."The items were: "I feel worried," "I feel tense" and "I feel upset."Each item had response options ranging from 1 ("does not describe my current state of mind at all") to 7 ("describes my current state of mind perfectly"), resulting in a scale ranging from 3 to 21. Internal consistency of the scale was good in all time points (T4: x ¼ .78,T5: x ¼ .81,T6: x ¼ .84,T7: x ¼ .84).
Anxiety over the Russo-Ukrainian war At T7 participants were asked to assess the impact that the Russo-Ukrainian war has had on their state anxiety.The three items adapted for this study were based on the short version of the Spielberger State-Trait Anxiety Inventory (Marteau & Bekker, 1992) and they were the same as those used for assessing COVID-19 anxiety.In the anchor, "COVID-19 crisis" was replaced with the "Russo-Ukrainian war" and the items were: "I feel worried," "I feel tense," and "I feel upset."Response option for each item ranged from 1 ("does not describe my current state of mind at all") to 7 ("describes my current state of mind perfectly"), resulting in a scale from 3 to 21.The scale had very good internal consistency (x ¼ .88).

Demographical variables
We included age, gender, and education (dummy coded to reflect having at least a bachelor's degree).In addition, dummy variables reflecting occupying a managerial position and being active in the working life at T4 were included.Participants were also asked to report their monthly gross income on a scale from 1 ("under 1000 euros") to 8 ("over 7000 euros").Finally, we used information about occupational area.Participants were asked to choose the field that best reflected their occupation based on the International Standard Industrial Classification of All Economic Activities (Official Statistics of Finland, 2008;United Nations, 2008), which were then classified into larger categories reflecting major economic sectors.

Statistical analyses
We conducted all statistical analyses with Stata 17 software.The descriptive results presented in Table 1 include means, standard deviations, Pearson's correlation coefficients with p-values and McDonald's Omega (x) coefficients for the study's main variables.Data from timepoints T4-T7 were used for comparing the mean levels of COVID-19 anxiety and anxiety over the Russo-Ukrainian war.The main analyses include data from T7 and consist of linear regression models on psychological distress.We report unstandardized regression coefficients (B) and their standard errors (B SE), standardized beta coefficients (b), p values, and model goodness-of-fit measures (adjusted R 2 ).We did not detect problematic multicollinearity, but we detected issues of heteroscedasticity of residuals based on a Breusch-Pagan test.Due to this, we run the models using robust standard errors (i.e., Huber-White standard errors).We detected outliers by looking at Cook's distance measure, where values greater than 4/N may cause problems.We run the models without these outliers (n ¼ 64).

Results
Descriptive results show that anxiety over the Russo-Ukrainian war at T4 was generally higher than COVID-19 anxiety at any of the considered timepoints (Figure 1).Linear regression model showed that both COVID-19 anxiety (b ¼ .45,p < .001)and anxiety over the Russo-Ukrainian war (b ¼ .20,p < .001)were significantly related to psychological distress.Those who remained employed at T7 reported higher psychological distress (b ¼ .06,p ¼ .027).Finally, income had a negative association with psychological distress (b ¼ À.12, p < .001).The whole model explained 36% of the variance in results.
The second model included the interaction between COVID-19 anxiety and anxiety over the Russo-Ukrainian war.In this model, the interaction (b ¼ .48,p < .001) was a significant predictor of psychological distress.As shown in Figure 2, psychological distress was especially high among participants reporting both high COVID-19 anxiety and anxiety over the Russo-Ukrainian war.COVID-19 anxiety also remained significant (b ¼ .20,p ¼ .003).Income was negatively related to psychological distress (b ¼ À.12, p < .001).The whole model explained 37% of the variance.Both models are included in Table 2.

Discussion
Results of Study 1 provided support for all the study hypotheses.Anxiety over the Russo-Ukrainian war was indeed higher than COVID-19 anxiety in the considered timeframe (H1).Moreover, results showed that both types of anxiety were related to psychological distress (H2, H3), and especially participants reporting high levels of anxiety related both to COVID-19 and the Russo-Ukrainian war reported high psychological distress (H4).Based on these results, our investigation was extended in Study 2.

Study 2
The purpose of Study 2 was to extend the investigation from Study 1, including effects of Russo-Ukrainian war anxiety and COVID-19 anxiety on perceived stress in addition to psychological distress, and to consider these effects among a representative sample of Finnish population.The study tested hypotheses H1-H7.Comparison of T1 sample characteristics to those provided by the official statistics of Finland found no major bias based on gender, age, education level, and area (Official Statistics of Finland, 2022a, 2022b;Oksanen et al., 2020).Nonresponse analysis between all T1 respondents (N ¼ 1530) and follow-up survey showed that there is no major drop out bias.However, respondents in the T3 sample were, on average, older than all T1 respondents (49.72 years vs. 46.67years).In the final sample, participants were 49.95% female, aged 19-76 (M ¼ 49.72, SD ¼ 16.16) and 38.51% had  obtained at least a bachelor's degree.Table 3 shows the descriptive statistics of the participants.
The research protocol was reviewed by the Academic Ethics Committee of the Tampere region who concluded that the research did not contain any ethical issues.Participants were informed that their participation is voluntary, and they can withdraw from the study at any time without providing any justification.The survey has been designed by the research group and data collection has been carried out by Nortstat.We conducted data integrity and quality checks after each collection phase.

Psychological distress
A shorter measure, namely the 5-item Mental Health Inventory (MHI-5; Berwick et al., 1991) was utilized instead of the General Health Questionnaire to measure psychological distress.Both measures are validated and commonly used in social science research.Using this shorter measure was more economical in a relatively long survey, and including various measurements in studies on similar topic provided a chance to replicate our results with a different setting and strengthen our conclusions.Each item (e.g., "How much of the time, during the past month, have you felt downhearted and blue?") had response options from 1 ("not at all") to 6 ("all the time") resulting in a scale ranging from 5 to 30.The internal consistency of the scale was very good (x ¼ .87).

Perceived stress
The Perceived Stress Scale (PSS, Cohen et al., 1983;Cohen & Williamson, 1988) was used to measure perceived stress.PSS consists of 10 items with response options from 0 ("never") to 4 ("very often"), and the final scale ranges from 0 to 40.The internal consistency of the scale was very good (x ¼ .87).

COVID-19 anxiety
The short version of Spielberger State-Trait Anxiety Inventory (Marteau & Bekker, 1992) was adapted to measure participants' anxiety over the COVID-19 crisis.We used the same measures and response options as in Study 1. Internal consistency of the scale was very good in all time points (T1: x ¼ .88;T2: x ¼ .87;T3: x ¼ .89).Anxiety over the Russo-Ukrainian war Three items concerning participants reactions to the Russo-Ukrainian war were used to assess their anxiety.These items were based on the short version of Spielberger State-Trait Anxiety Inventory (Marteau & Bekker, 1992) as in Study 1. Internal consistency of the scale was very good (x ¼ .86).

Demographic information
We included demographic information, namely participants' age, gender, education (dummy coded to reflect having at least a bachelor's degree).In addition, we asked participants to report if they have children (0 ¼ no, 1 ¼ yes) and their current employment status (employed, entrepreneur, student, unemployed, retired, or other).

Statistical analyses
All statistical analyses were performed using Stata 17 software.Table 3 includes descriptive data concerning the study's variables, including means, standard deviations, Pearson's correlation coefficients with p-values and omega (x) coefficients for scale variables.Data from timepoints T1-T3 were used for comparison of mean levels of COVID-19 anxiety and anxiety over the Russo-Ukrainian war.Main analyses were based on T3 data and consisted of linear regression models for psychological distress and perceived stress.We report the results as in Study 1. Similar to Study 1, check of linear regression assumptions showed issues with heteroscedasticity of the residuals and outliers.Due to these, we ran the models using robust standard errors and outliers detected with Cook's distance measure (n ¼ 61) were omitted.
In the second model, the interaction effect of COVID-19 anxiety and anxiety over the Russo-Ukrainian war was examined.The interaction (b ¼ .29,p ¼ .002)had a significant association with psychological distress.
Table 5 presents results of the linear regression analysis on perceived stress.Both COVID-19 anxiety (b ¼ .45,p < .001)and anxiety over the Russo-Ukrainian war (b ¼ .21,p < .001)were positively related to perceived stress.Female gender (b ¼ .05,p ¼ .022)and being a student (b ¼ .06,p ¼ .025)had a similar effect.Older age (b ¼ À.20, p < .001),higher income (b ¼ À.07, p ¼ .009)and higher education (b ¼ À.08, p ¼ .001)were negatively related to perceived stress.The whole model accounted for 50% of the variance.In the second model, interaction between COVID-19 anxiety and anxiety over the Russo-Ukrainian war was entered, but it did not have a significant impact on the results (b ¼ .03,p ¼ .757).

Discussion
Results of Study 2 provided support for most of the study hypotheses.Results from Study 1 were replicated, with anxiety over the Russo-Ukrainian war being higher than COVID-19 anxiety in any of the considered timepoints (H1).Both types of anxiety were associated with psychological distress (H2, H3) and participants reporting high anxiety over the war and COVID-19 simultaneously, suffered from notably high psychological distress (H4).This study also included investigation of effects of both types of anxiety on perceived stress.As expected, anxiety over the Russo-Ukrainian war (H5) and COVID-19 anxiety (H6) were associated with higher perceived stress, supporting the hypotheses.However, contrary to expectations, they did not have a combined effect on perceived stress (H7).

General discussion
This research aimed to investigate the influence of the prolonged COVID-19 crisis and Russia's full-scale attack on Ukraine on the mental health of Finnish population.We found that in spring 2022 anxiety related to the Russo-Ukrainian war was higher than COVID-19 anxiety in all the considered timepoints starting from autumn 2020.In two studies, we found a negative effect of both crises on psychological distress and perceived stress of the participants.Psychological distress was especially high among participants reporting high anxiety about both the COVID-19 crisis and the Russo-Ukrainian war.Overall, as expected, results of both Study 1 and Study 2 clearly indicated that anxiety about Russia's full-scale attack on Ukraine is stronger than anxiety about the COVID-19 crisis, confirming our expectations (H1).Similarly, all of our hypotheses concerning the impact of anxieties related to both crises on psychological distress (H2-H4) were strongly supported by the results of Study 1 and Study 2.Moreover, hypotheses concerning the impact of anxieties about the COVID-19 crisis (H5) and the Russo-Ukrainian war (H6) on perceived stress were tested in Study 2 and supported by its results.However, contrary to our predictions, we found no combined effect of these anxieties on perceived stress (H7).
Our results show that during the first months of Russia's full-scale attack on Ukraine, war-related anxiety was significantly higher than COVID-19 anxiety.At the same time, COVID-19 anxiety did not drop significantly as compared to levels from before February 2022.Our models further demonstrated the burdening effect of the co-existence of both crises, showing with two samples how COVID-19 anxiety combined with anxiety over the Russo-Ukrainian war is associated with significantly higher psychological distress.This result on cumulative effect of stressors is in line with previous studies concerning life-stressors (Lloyd & Turner, 2003;Turner & Lloyd, 1995), and especially those representing traumatic, large-scale stressors such as the COVID-19 pandemic and the Russo-Ukrainian war (Dubow et al., 2012;Savolainen et al., 2021;Sheather, 2022).Prior pandemics and exposure to conflict and violence have been shown to have long-term mentalhealth impacts on people experiencing them (Huremovi c, 2019;Kurapov et al., 2023;Rozanov, 2019) and accumulated traumatic and stressful events have been shown to result in greater risk for mental health problems (Lloyd & Turner, 2003;Turner & Lloyd, 1995).It should be highlighted, however, that the current situation in Europe is exceptional as the concurrent existence of pandemic and war creates an unprecedented crisissituation that touches hundreds of millions of people directly or indirectly.The scale of these crises alone poses vast challenges and the cumulative long-term effects on people's well-being are yet to be discovered.The results of this study indicate that when a new crisis emerges on top of an existing one, the burdening effect increases.
Despite the higher anxiety about the Russo-Ukrainian war as compared to COVID-19 anxiety, COVID-19 anxiety had a stronger effect on psychological distress and perceived stress, and that effect remained significant after including interaction of both types of anxiety in the models.This is probably due to a more concrete threat to personal health and safety posed by the COVID-19 crisis as compared to the Russo-Ukrainian war.Even though the war has caused serious concern among Finnish people and major changes in the way the country perceives its role in the region (i.e., joining NATO as a direct result of the war; YLE, 2022c), the ongoing Russo-Ukrainian war does not directly involve the Finnish state and most of the country's population.However, it is also clear from the results that the escalation of the Russo-Ukrainian war has already had a significant negative effect on well-being in the Finnish population.This impact is likely to increase and stretch into the future, depending on the dynamics of the conflict and its economic and security consequences for the region.

Practical implications
Considering that COVID-19 has already resulted in a large increase in the demand for psychological help (American Psychological Association, 2020; Kestil€ a et al., 2022), potential long-time burden on healthcare brought about by the combined impact of both crises should be taken into consideration by practicians and decisionmakers.Deterioration of mental health was observed especially among those with lower income, unemployed, females and students.The findings are partly in line with prior research, which indicates that females, younger people, and those who have lower educational attainment, and lower income experienced higher COVID-19 anxiety and depression in the early stages of the pandemic (Fancourt et al., 2021).Moreover, students have reported lowered mental well-being (Kurapov et al., 2023) and female gender has been associated with higher levels of anxiety during the Russo-Ukrainian war (Riad et al., 2022).Hence, targeting mental health interventions and support as well as reinforcing coping skills and resilience are vital.
Emerging research on the Russo-Ukrainian war as well as past studies on other military conflicts suggest that the frequency and duration of news consumption on war has negative mental health outcomes (Garfin et al., 2020;Malka et al., 2015;Riad et al., 2022;Surzykiewicz et al., 2022).This was also evident after the 9/11 terrorist attacks that impacted U.S. residents across the country.Media-based (i.e., live television) exposure to the major tragedy was related to 9/11 posttraumatic stress up to six years after the occurrence (Garfin et al., 2018).Similar results have been obtained concerning the COVID-19 crisis (Hoyt et al., 2022).Therefore, limiting the news intake may help manage the harmful effect of crises on individuals' mental health.
Overall, the present research clearly demonstrates a need for mental health interventions in the population during major crises such as pandemics and war in the region.The results show that anxiety related to these difficult situations is associated with psychological distress and perceived stress, which in turn can lead to prolonged negative health outcomes (Bovier et al., 2004;Rai et al., 2012).The burdening effect of coexisting crises further accentuates this need for interventions.Based on our results, the groups especially at risk of these negative outcomes include females, young people, and students, as well as those struggling financially.This finding has been shown in prior studies as well (Bonanno et al., 2007;Neria et al., 2008).Therefore, it could be beneficial to target mental health interventions for these groups that are more vulnerable to the effects of crises.Efforts should focus on making mental health services visible and accessible to them.Important directions of future research include further investigation of these negative mental health outcomes of crises, using various methods and measures, and focusing on the prolonged effects as the situation develops, or even after the crisis is resolved.Moreover, experimentally testing the effectiveness of relevant mental health interventions remains a crucial research avenue.

Strengths and limitations
An important strength of our research is the fact that we obtained similar results in two studies using two different, representative samples, making our conclusions compelling.However, as both the COVID-19 crisis and the Russo-Ukrainian war have impacted countries differently, due to geopolitical situation and other factors, any generalization of our results beyond the Finnish population needs to be approached with caution.Moreover, our data were collected in the beginning of the full-scale attack, in spring 2022.Future studies should explore its long-term effects on indirectly affected populations.Future studies could also utilize a wider variety of measures, including longer scales for measuring anxiety induced by crises such as war.

Conclusions
The beginning of Russia's full-scale attack on Ukraine in February 2022 was a major escalation of the long-lasting Russo-Ukrainian conflict and spawned uncertainty in the region, while overlapping with the ongoing COVID-19 pandemic.Our results based on two large population samples showed that a few weeks into the conflict, Russo-Ukrainian war related anxiety among Finnish population was higher than COVID-19 anxiety at any timepoint from autumn 2020.We demonstrated the negative effects of both these crises on mental health.Russo-Ukrainian war related anxiety and COVID-19 anxiety were associated with increased psychological distress and perceived stress.Psychological distress was especially high among those participants who experienced high anxiety over both COVID-19 and the war.These results show the especially heavy combined effect of both crises on mental health.Practitioners and decision-makers should take this into consideration when allocating resources and planning future care.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Figure 2 .
Figure 2. Interactional impact of COVID-19 anxiety and anxiety about the Russo-Ukrainian war on psychological distress in Study 1.

Figure 4 .
Figure 4. Interactional impact of COVID-19 anxiety and anxiety about the Russo-Ukrainian war on psychological distress in Study 2.

Funding
Study 1 received funding from the Finnish Work Environment Fund (Professional Social Media Use and Work Engagement Among Young Adults Project, project number 118055, PI: Atte Oksanen), Finnish Cultural Foundation (Technology-mediated Communication at Work during COVID-19 Crisis: A Longitudinal Study on Occupational Wellbeing 2019-2022, PI: Atte Oksanen) and from Tampere University, Finland (PI: Atte Oksanen).Study 2 was funded by the Finnish Foundation for Alcohol Studies (Gambling in the Digital Age Project, 2021-2022, PI: A. Oksanen).

Table 1 .
Descriptive statistics of the Study 1 variables.

Table 3 .
Descriptive statistics of the Study 2 variables.

Table 5 .
Study 2 linear regression models on perceived stress.