key: cord-281807-9ji263b7 authors: tamiolaki, alexandra; kalaitzaki, argyroula e. title: “that which does not kill us, makes us stronger”: covid-19 and posttraumatic growth date: 2020-04-30 journal: psychiatry res doi: 10.1016/j.psychres.2020.113044 sha: doc_id: 281807 cord_uid: 9ji263b7 nan suggested that ptg describes the positive changes experienced by people as a result of their cognitive efforts to deal with challenging circumstances. growth occurs when people in the aftermath of trauma engage in a deliberate cognitive restructuring of reality, by changing their life narrative to include a better understanding of the self, the others, and the world (tedeschi and calhoun, 1996) . (lau et al., 2006) . in the research of lau et al. (2006) , although a high percentage of people experienced feelings of worry, helplessness, isolation, irritation, sleeping problems and many other negative mental health effects during the sars outbreak, for a proportion of people, sars was also considered a chance for positive outcomes. they experienced 'social growth', as they reported greater care about their family members' feelings, were more likely to be spending time together and considered their friends more supportive. they also achieved 'personal growth', as they were spending more time to relaxand they adopted a healthier lifestyle. also, they learnt to be grateful and appreciate their health, family, friends and everyday life, all of which are aspects of 'spiritual growth' (lau et al., 2006 posttraumatic stress symptoms and attitude toward crisis mental health services among clinically stable patients with covid-19 in china positive mental health-related impacts of the sars epidemic on the general public in hong kong and their associations with other negative impacts prevalence and predictors of ptss during covid-19 outbreak in china hardest-hit areas: gender differences matter the posttraumatic growth inventory: measuring the positive legacy of trauma key: cord-312356-95yyi0jb authors: hernández-huerta, daniel; alonso-sánchez, elena begoña; carrajo-garcia, carmen aldara; montes-rodríguez, josé manuel title: the impact of covid-19 on acute psychiatric inpatient unit date: 2020-05-19 journal: psychiatry res doi: 10.1016/j.psychres.2020.113107 sha: doc_id: 312356 cord_uid: 95yyi0jb nan make the virus difficult to contain: they lack respiratory isolation rooms, doors are firmly closed, wards are poorly ventilated and some patients have shared rooms, among others. moreover, mental health staff often has inadequate training on the management of respiratory infectious diseases, which adds to some features of patients with pre-existing mental health conditions, such as inadequate insight or psychomotor excitement, being unable to practice infection control measures, as well as limited awareness regarding the risk of infection, that may contribute to the transmission of covid-19. in fact, it has been evidenced that psychiatric patients are more susceptible to respiratory infections than general population (xiang et al., 2020) . we are also facing new diagnostic challenges, as many patients admitted to the psychiatric ward are simultaneously been treated for covid-19. some drugs used to treat the sars-cov-2 pneumonia are associated with neuropsychiatric adverse events, which must be taken into consideration in the differential diagnosis. they can also have life-threatening interactions with psychotropic drugs, leading to increased toxicity and undesirable side-effects, such as qt interval prolongation (uvais, 2020) . hidroxicloroquine, lopinavir/ritonavir and corticosteroids can cause from mild complications, such as mood lability, depression or nervousness, to severe manifestations including psychosis, excitement and delirium (abers et al., 2014; oray et al., 2016; uvais, 2020) . additionally, we ought to be aware of other atypical neurological symptoms caused by sars-cov-2 neurotropism, as a recent case of encephalitis has already been reported (moriguchi et al., 2020) . furthermore, complementary treatments such as psychological and occupational therapy, family accompaniment or coordination with the outpatient clinics have been reduced or abolished. similar difficulties have been described in delivering electroconvulsive therapy because of the shortage of personal protective equipments for healthcare staff who cannot perform such essential therapy in safe conditions (tor et al., 2020) . regrettably, because of the shortage of isolation rooms for sars-cov-2 positive cases who suffer from mental illness decompensation comorbidities, physical restraint practices could increase in order to guarantee confinement and infection control measures. all of these aspects above sadly seem to contribute to hinder inpatients' recovery process. the covid-19 pandemic will probably lead to unprecedented changes in our national health care system, as well as in the mental health system. we call for the creation of state policies that mitigate the health impact of such catastrophe, with urgency in relation to patients at acute psychiatric inpatient units. these policies should include contingency plans alongside the redesign of healthcare settings to ensure that they will be suitable for new future outbreaks. despite the ongoing health crisis, certain changes must be undertaken if we want to continue bringing acceptable healthcare for individuals with mental disorders. neurological and psychiatric adverse effects of antiretroviral drugs lessons learned from the coronavirus health crisis in madrid, spain: how covid-19 has changed our lives in the last two weeks a first case of meningitis/encephalitis associated with sars-coronavirus-2 long-term side effects of glucocorticoids ect in a time of covid-19 the risks of prescribing hyodroxychloroquine in covid-19-infected patients with schizophrenia the covid-19 outbreak and psychiatric hospitals in china: managing challenges through mental health service reform key: cord-302240-wpwwetrs authors: hölzle, patricia; aly, lilian; frank, wolfgang; förstl, hans; frank, andreas title: covid-19 distresses the depressed while schizophrenic patients are unimpressed: a study on psychiatric inpatients date: 2020-06-05 journal: psychiatry res doi: 10.1016/j.psychres.2020.113175 sha: doc_id: 302240 cord_uid: wpwwetrs nan the covid-19-pandemic has distressed most people all over the world during spring 2020, and the situation has been particularly hard on patients with mental disease (frank et al., 2020; hao et al., 2020 , hernández-huerta et al., 2020 , tian et al., 2020 . two months after the beginning of the lock-down with social distancing, job losses and fear of infection, we have examined a sample of psychiatric inpatients in the middle of may 2020 in order to quantify mental and somatic distress and compare between different diagnostic groups. the following scores were used: clinical global impression (cgi; billen et al., 2020) ; the perceived stress scale (pss; klein et al., 2016) , and a summary score of stress-related somatic complaints (srs): headache, lower back pain, exhaustion, difficulties falling asleep, insomnia, irritability, hostility, restlessness, boredom, altered eating habits, maldigestion scores for each item was between 0 for "never" and 6 for "almost permanently". we examined a sample of 139 patients (61m, 78f) with a mean age of 48 years (from 18 to 92). among these 139 patients, 17 suffered from disorders due to psychotropic substances (icd-10 f1.x), 26 were diagnosed with schizophrenia and related disorders (f2.x), 89 presented with affective disorders (f3.x), and 7 individuals had other psychiatric diagnoses. cgi in the total sample was 4.9 (sd 1.0) and was significantly higher in women compared to men (ttest, p = 0.03). there were no significant differences between the f1 (dependence), f2 (psychosis) and f3 (affective disorders) groups regarding the cgi-score. pss and srs were highest in the affective disorders group compared to the rest of the sample (anova; both p ≤ 0.0001). ancova showed that this difference remained significant when controlled for gender (ancova; both p ≤ 0.0001). cgi was not significantly correlated with stress perceived during the last month (pss; spearman coefficient; p > 0.05), but with the srs (spearman coefficient; p ≤ 0.0001) in the total group. the subgroup with affective disorders showed the highest correlations between cgi and pss or srs, whereas no such relationship at all was observed in the schizophrenia and related disorders group. this may indicate a differential effect of a global crisis for patients with affective and psychotic disorders. collective anguish will resound more strongly in vulnerable individuals whose emotions are in need of a corresponding narrative, while patients with schizophrenia are occupied with serious intrinsic issues and unperturbed by comparably mundane worldly business. antipsychotic treatment does contribute its share to the pseudo-resilience in the f2-group. patients with affective disorders are more likely to seek help in times of crisis, while self-isolating patients with schizophrenia and similar diseases are in need to be found. clinical global impression -corrections (cgi-c) -deutsche übersetzung. forensische psychiatrie, psychologie depression, dependence and prices of the covid-19-crisis do psychiatric patients experience more psychiatric symptoms during covid-19 pandemic and lockdown? a case-control study with service and research implications for immunopsychiatry the impact of covid-19 on acute psychiatric inpatient unit the german version of the perceived stress scale -psychometric characteristics in a representative german community sample psychological symptoms of ordinary chinese citizens based on scl-90 during the level i emergency response to covid-19 key: cord-314874-6ey87o16 authors: palomar-ciria, nora; alonso-álvarez, daniel; vázquez-beltrán, pilar; blancodel valle, patricia title: commentary to “schizophrenia and covid-19 delirium”, an update date: 2020-11-04 journal: psychiatry res doi: 10.1016/j.psychres.2020.113555 sha: doc_id: 314874 cord_uid: 6ey87o16 nan since the outbreak of coronavirus disease 19 , atypical presentations that include neuropsychiatric conditions have been observed in infected patients (nalleballe et al., 2020; rogers et al., 2020) . neuropsychiatric symptoms are present in more than half the cases (romero-sánchez et al., 2020) . herein, we would like to provide an update based on the case of mr. s. (palomar-ciria et al., 2020) , who was discharged on may 31 st , although he had not yet fully recovered. patient's health has been improving slowly, and he was discharged from the hospital on the belief that being at home would help him to get better. a few days later, on june 5 th , he was taken to the emergency room due to a suicide attempt. he explained he felt awful that day "because of my eyes" and he also said that he wanted to "be reborn". mr. s. used the window to descend from the third floor to the first floor, but he lost balance and fell. in the emergency room, fractures and other lesions were ruled out and he was hospitalized in the psychiatric unit again. antipsychotic treatment was reinforced and an antidepressant was added. during the first days of hospitalization, the predominant symptoms were disorganized behavior, reiterative or blocked speech, bradyphrenia, disorientation, apraxia, echolalia and bradykinesia without rigidity. he did not express suicidal thoughts and he hardly remembered anything from his suicide attempt. he showed poor response to psychopharmacological treatment, so it was gradually reduced to a very low dose in order to clarify diagnosis. vital signs were maintained during his stay and fever or other signs of physical disease were not detected. mr. s. condition neither improved nor worsened. however, he started to show dysphoric mood without agitation or behavioral disturbance. at this point, we had reasons to suspect a catatonic episode, and we requested anesthesiology assessment to start electroconvulsive therapy (ect). the first session of ect took place on on july 21 st . that very day, he started to be more talkative, prone to approaches and cheerful. he received five more sessions without secondary effects. he was finally discharged on august 7 th , when he was fully recovered. presently, he remains free of symptoms, and he can lead an active life. catatonia is a rare neuropsychiatric condition that has been rarely associated to covid-19 (caan et al., 2020) . it is a severe condition that can be treated properly if it is recognized. covid-19 exhibits potential neurotropic properties and we must reinforce the idea that catatonic signs could be observed, especially in psychiatric patients, who are a population at risk of this new disease. as knowledge on the medical aspects of the infection increases, research on the psychiatric symptoms of covid-19 should be warranted. a case of catatonia in a man with covid-19 spectrum of neuropsychiatric manifestations in covid-19 schizophrenia and covid-19 delirium psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the covid-19 pandemic neurologic manifestations in hospitalized patients with covid-19: the albacovid registry we want to thank the anesthesiology service of the complejo asistencial de soria for their work and i.r. for her suggestions. key: cord-277824-q7blp3we authors: bilal; latif, faiza; bashir, muhammad farhan; komal, bushra title: role of electronic media in mitigating the psychological impacts of novel coronavirus (covid-19) date: 2020-04-29 journal: psychiatry res doi: 10.1016/j.psychres.2020.113041 sha: doc_id: 277824 cord_uid: q7blp3we the current research initiative focuses on the role of pakistani media in eliminating panic and depression among health practitioners and the general public due to the outbreak of novel coronavirus (covid-19). in pakistan, electronic media is the most common source of information due to the higher rural population and the lower literacy rate and media's handling of covid-19 coverage so far creates panic and depression. we suggest that special televised transmissions featuring psychologists and physiatrists should be aired to reduce the panic. media also mitigates the stress of frontline medical staff by paying special attributes to them. abstract: the current research initiative focuses on the role of pakistani media in eliminating panic and depression among health practitioners and the general public due to the outbreak of novel coronavirus . in pakistan, electronic media is the most common source of information due to the higher rural population and the lower literacy rate and media's handling of covid-19 coverage so far creates panic and depression. we suggest that special televised transmissions featuring psychologists and physiatrists should be aired to reduce the panic. media also mitigates the stress of frontline medical staff by paying special attributes to them. keywords: covid-19; media; mental health. during times of public crises, media must ensure to communicate crisis information efficiently and effectively to the general public, failing to do so will certainly lead to uncertainty, fear, and anxiety. in this era of advancement and technology with the general acceptance for freedom of speech, the role of media becomes indispensable in every respect. as today the world is suffering from ongoing novel coronavirus pandemic, fear of getting infected is sweeping all over the globe. in this context, some sources may be of dire help and play their part in reducing the panic that has been caused due to an increase in the mortality rate all over the globe (wit et al., 2011) . media is the most powerful tool that can disseminate such campaigns to provide some relief from panic and boost the morale of the general public. there is a general acceptance of the fact that electronic and print media in south asia are politically biased and tend to exploit scenarios like the current situation to win media wars. this is why we should focus on the role media to help reduce anxiety levels in the general public. history shows that there is a direct link between media and society. the basic motive of media is to inform society and to work for social welfare at a massive level as it targets the mass population. this particular study aims to study the role of pakistani media in reducing the mental stress of the public and enhancing the motivation level of the healthcare service providers during the covid-19 pandemic. (mckibbin & fernando, 2020) . media campaigns in pakistan need to address the mental health of the public and there is a great need for special transmissions with health professionals and experts to provide advice and instructions for the public to cope with the current situation (ali & gatiti, 2020) . pakistani media generally enjoys broadcasting freedom and has a strong impact on the day-to-day life of the general public. the current situation demands that they should play a positive role in this critical condition for the well-being of the general public. psychologists, psychiatrists and healthcare professionals should be invited in the programs to guide the people about the covid-19 with the aim to console and advise the general public on how to avoid stress so that they can cope with this deadly condition without affecting their mental health. special televised campaigns aimed to boost the morale of the public should be given air time (bhatia, 2018) . another dilemma of the current situation is the absence of schooling of children. children are at home and are moved with the situation. the media is not on-airing any productive program for children which shows that pakistani media is only limited to just one age group in society. what about children who are the future of our society and are already suffering from boredom and depression during the current situation, therefore media should play its role in arranging some special programs aimed at promoting learning activities for children and it will be beneficial for the mental and physical developments of these children who are the future of the covid-19 (coronavirus) pandemic: reflections on the roles of librarians and information professionals role of media to inform public about depression related diseases covid-19 risks and response in south asia the global macroeconomic impacts of covid-19: seven scenarios are sedentary television watching and computer use behaviors associated with anxiety and depressive disorders? key: cord-288022-xh10ccki authors: wu, dongmei; jiang, chunyan; he, changjiu; li, chao; yang, lei; yue, yuchuan title: stressors of nurses in psychiatric hospitals during the covid-19 outbreak date: 2020-04-14 journal: psychiatry res doi: 10.1016/j.psychres.2020.112956 sha: doc_id: 288022 cord_uid: xh10ccki nan in early february 2020, novel coronavirus infection occurred in the wuhan mental health center, and a total of about 80 patients and medical staff were diagnosed. this was the first novel coronavirus epidemic in psychiatric hospitals in china. as of february 18, 2020, novel coronavirus pneumonia was diagnosed in 323 patients with severe mental disorders, covering 17 provinces in the country (china, 2020) . the epidemic makes it hard for psychiatric nurses to work. through phenomenological research, 18 psychiatric nurses were interviewed. the male to female ratio of the study subjects was 6:12, whose age ranges from 25 to 54 years old. in addition, most of them have married and possessed their own family. furthermore, their lever of nursing education ranges from junior college degree to graduate degree. the majority of nurses have a bachelor's degree. the average years of nursing in psychiatric hospitals are 14.5 years. they are equipped with extensive clinical experiences. the participants worked in a psychiatric hospital with more than 1200 inpatients during the covid-19 outbreak located in chengdu city, sichuan province, in the west of china. five stressors were identified from the interview data. first, higher exposure risks than peers in general hospitals. to begin with, the patients often lived in crowded wards. in addition, although general clinics were closed, 3 to 5 psychiatric patients with severe symptoms, especially aggressive behaviors, were admitted from the emergency room every day. most of them could not provide accurate epidemiological histories under the symptoms. moreover, patients also had various risk behaviors to the medical staff, such as tearing safety goggles and masks of medical staff, and even spitting to them. second, inadequate preparedness for the outbreak. psychiatric nurses tended to lack knowledge about coping with infectious diseases (zhu et al., 2020) . they had to process large volumes of information in a short time, such as covid-19 prevalence, viral pathogens, symptoms and signs of patients, protection level. the lack of contingency plans for public health emergencies in the psychiatric hospital also brought big challenges to nurses' daily work. third, conflict with the original professional value. during the outbreak, some psychiatric nurses suddenly found that they were not as good as a novice nurse who worked in the respiratory department or icu. "i have been working in the psychiatric hospital for 14 years, but recently i feel so sorry for being a psychiatry nurse. when i saw those nurses working in the front line of anti epidemic in wuhan on tv, i began to blame myself for not being a nurse in the respiratory department or icu. " fourth, the role conflict between family and work. traditional chinese families usually live together with three generations. adults are responsible for the care of elderly parents and young children (liu et al., 2020) . during the outbreak, the daily care of the elderly parents, especially with various chronic diseases, become a major problem. in addition, due to the full suspension of school, nurses also needed to provide homework tutoring after work for their own children receiving online school education at home. nurses were struggling with these responsibilities. nurses were also worried about themselves to be carriers of new coronavirus, causing cross infection between patients and family members. finally, the delay of personal life and career planning. due to the epidemic, nurses had to postpone their original personal life plans, such as marriage, childbirth, or traveling abroad. the original plan to go abroad for vocational training or further study also fell apart. the results of the study could draw the world's attention to the stressors of psychiatric nurses during the covid-19outbreak, help solve their problems and reduce the turnover of psychiatric nurses during the outbreak and afterwards. the authors declare that they have no conflicting interests. psychiatric hospitals should better care for mental patients during novel coronavirus outbreak family structure and competing demands from aging parents and adult children among middle-aged people in china the risk and prevention of novel coronavirus pneumonia infections among inpatients in psychiatric hospitals key: cord-296708-b37jcj4f authors: sagar, rajesh; chawla, nishtha; sen, mahadev singh title: is it correct to estimate mental disorder through online surveys during covid-19 pandemic? date: 2020-06-22 journal: psychiatry res doi: 10.1016/j.psychres.2020.113251 sha: doc_id: 296708 cord_uid: b37jcj4f nan covid-19 infection hit the globe in late 2019 and spread widely across multiple nations to infect more than 5 million people across the world by this date. since then, there have been multiple research articles on psychological impact of covid-19 and the situation associated with it (e.g. quarantine, social isolation, physical distancing, etc.). many researchers are resorting to online surveys, abiding by physical distancing rules, to assess its psychological currently. a narrative review of mental health and covid-19 showed that 28 articles have been published of which 4 are original studies, all from china. 1 two out of these four studies were done through online survey or mobile app. 2, 3 the rates of psychiatric disorders through various online surveys have come out to be much higher than general population. [2] [3] [4] however, it is important to note that the validity of diagnosis based on checklist items in online surveys is not similar to face-to-face interviews, as psychiatric diagnosis are different form medical diagnosis, which is largely pathophysiological. psychiatric diagnosis requires fulfilment of criteria outlined in the diagnostic classificatory systems as well as should be associated with clinically significant 'dysfunction/ distress or impairment'. several psychiatric diagnoses may be misclassified if the psychosocial dysfunction/ distress is not taken into account, similar to what has been called as 'clinical significance criterion' in dsm or 'clinically recognisable symptoms' in icd. it has been acknowledged that such signs and symptoms may be present in general population and may be normal variant. 5 hence, face-to-face interviews are considered gold-standard. often the dysfunction and distress related to the illness is not emphasized upon in such surveys. it was emphasized in the universal online survey of world mental health international college student (wmh-ics) that overestimation is likely. 6 some more points to be considered include the significance of assessing occupational status at the time of lockdown, quarantine, and social isolation, as practically employed individuals may also be less engaged in work (unless working from home). of course, being employed would increase the sense of security and financial issues. the significance of occupation may be different from what usually is. it is, thus, important to view these results in the light of caution as the we need to limit the panic which may be created related to spurious rising prevalence of psychiatric morbidity and may unnecessary expose to pharmacological agents. there is also a possibility of promoting medications in the population which may not indeed be required. it also holds implications in guiding the policy makers who formulate the guidelines for managing psychiatric morbidities during this time. the researchers may use terms like 'symptoms' in their estimation instead of claiming estimation of 'diagnosis/ disorder'. 4 in the same study the term "depressive symptoms" was used but also mentioned generalised anxiety disorder without significant dysfunction/distress criterion . the intention of this paper is not to downplay the efforts of the researchers trying to estimate the illnesses while avoiding physical interaction, but to alert the readers in being cautious in interpreting the results. covid-19 and mental health: a review of the existing literature immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china vicarious traumatization in the general public, members, and non-members of medical teams aiding in covid-19 control generalized anxiety disorder, depressive symptoms and sleep quality during covid-19 outbreak in china: a web-based cross-sectional survey three approaches to understanding and classifying mental disorder: icd-11, dsm-5 , and the national institute of mental health's research domain criteria (rdoc) accuracy of online survey assessment of mental disorders and suicidal thoughts and behaviors in spanish university students. results of the who world mental health-international college student initiative key: cord-333875-alx5uc95 authors: rajkumar, ravi philip title: contamination and infection: what the coronavirus pandemic could reveal about the evolutionary origins of obsessive-compulsive disorder date: 2020-05-05 journal: psychiatry res doi: 10.1016/j.psychres.2020.113062 sha: doc_id: 333875 cord_uid: alx5uc95 nan the global outbreak of novel coronavirus disease has had a farreaching impact on the mental health of people across the world. of particular interest was the report in your journal about the potential of this outbreak to cause an exacerbation of obsessive-compulsive disorder (ocd) symptoms in vulnerable patients (banerjee, 2020) . while this concern is timely and of clinical significance, it also invites a response from a complementary perspective, many of the behaviours that have been observed in response to the covid-19 pandemic resemble the compulsive acts of patients with ocd. in some cases, these behaviours are adaptive and based on scientific opinion, but retain the form of ritualsfor example, the elaborate procedures described for hand hygiene and the use of protective equipment advocated by the world health organization. in others, these behaviours appear less rationalfor example, the hoarding of protective equipment and sanitary supplies. this similarity raises an interesting question: is there evidence of a significant relationship between certain aspects of ocd and behavioural responses (adaptive or maladaptive) to infectious disease outbreaks? evidence from phenomenology, evolutionary theory and neurobiologyincluding the study of culture-gene co-evolutionsuggests that this probably is the case, and that such a viewpoint could inform our understanding of ocd and its treatment. phenomenological approaches to ocd suggest that it is not a unitary disorder. while the phenomenological similarity described above is suggestive, more convincing evidence of an association between some dimensions of ocd and behaviours that minimize the risk of infection can be obtained from evolutionary theory. in particular, it has been proposed (a) that fears of contamination and ritualistic washing-related behaviours might have played a role in improving sanitary standards and improved the general health of ancient tribes, and (b) that hoarding could represent a form of altruistic behaviour in the face of scarce and time-limited resources in hunter-gatherer societies (polimeni et al., 2005) . the application of these theories to a situation such as the covid-19 outbreak, characterized by both a risk of infection and resource scarcity due to curfews and lockdowns, is evident. thus, at least some ocd symptomsmost specifically washing rituals, and less specifically hoarding behaviour -have evolutionary as well as current parallels to behaviours that confer a survival advantage in the face of infectious disease outbreaks and the privations that they may cause. the above speculations gain some strength from two lines of research into the pathogenesis of obsessive-compulsive disorder. first, contemporary research has identified a close cognitive and neurobiological overlap between ocd and the basic human emotion of disgust. from an evolutionary perspective, disgust serves as a motivator in the avoidance of infectious disease, and has been linked most closely to the contamination/cleaning dimension of ocd. certain key brain regions, such as the insula and the anterior cingulate cortex, show increased activation both in ocd and in experiments designed to provoke disgust in normal individuals, underlining the link between the two. thus, disgust could be an important link between evolutionary adaptations against infection and ocd (bhikram et al., 2017) . second, from an evolutionary perspective, increased pathogen load has been historically associated with selection pressure for the short (s) allele of the serotonin transporter gene (5-httlpr) (chiao and blizinsky, 2010) . on the other hand, ocd has been consistently associated with the long (l) allele of 5-httlpr. therefore, it is possible that polymorphisms in serotonergic genes might underline the similarities and differences between ocd and behaviours that have protected humans from infectious pathogens in the pastand continue to do so now. in conclusion, the above evidence suggests that there may be close links between some dimensions of ocd and behaviours that evolved to protect our ancestors from infectious disease, and which continue to do so now in a modified form. disease outbreaks such as the covid-19 crisis are, in a sense, "experiments of nature" that allow researchers to investigate such links further. a careful study of the behavioural patterns of human response to disease outbreaks, and their neurobiological and the other side of covid-19: impact on obsessive-compulsive disorder (ocd) and hoarding ocd: obsessive-compulsive….disgust? the role of disgust in obsessive-compulsive disorder culture-gene coevolution of individualismcollectivism and the serotonin transporter gene a multidimensional model of obsessive-compulsive disorder could obsessive-compulsive disorder have originated as a group-selected adaptive trait in traditional societies? the author wishes to thank all the publishers and authors who have made covid-19related research freely accessible. the author reports no potential or current conflicts of interest with regards to this work.funding source: no sources of funding were received for this work. key: cord-300617-sntnel5p authors: hill, patrick l.; burrow, anthony l. title: derailment as a risk factor for greater mental health issues following pandemic date: 2020-05-13 journal: psychiatry res doi: 10.1016/j.psychres.2020.113093 sha: doc_id: 300617 cord_uid: sntnel5p nan the recent pandemic has proven to be a destabilizing force worldwide, sending economies and social arrangements off course to an extent that will be felt for years to come. similarly, covid-19 has thrown nearly everyone's personal lives off their typical course. just as policymakers are dealing with how to restructure a derailed world, people are also left to determine how much of their "normal lives" can continue in this uncertain time. often missing in discussions is the immense mental health challenge we are facing as a result of the pandemic and our response (schwartz, 2020) . given the need for mental health professionals to target interventions and limited resources to those most in need, we suggest there is value for mental running head: derailment in a pandemic 2 health professionals to assess these feelings of derailment -an individual's sense of disconnection from their past selves, life directions, and motivations (burrow, hill, ratner, & fuller-rowell, 2020) . this recommendation is rooted in the construct's clinical relevance, ease of assessment, ability for intervention, and connection to the ongoing crisis. when considering the current environment, the covid-19 pandemic presents with several factors that researchers for decades have suggested will lead to greater impact from major life events (for a review, see luhmann, fassbender, alcock, & haehner, 2020) . given this event is truly a once-in-a-lifetime pandemic (world health organization, 2020), most individuals will view the event as extremely negative in valence, unpredictable, largely outside their own ability to control it, and relatively extraordinary in nature, insofar that it is unlike any past events they have experienced. all of these factors will likely play a contributing role with respect to several mental health concerns. in addition, the potential for derailment to prove a lingering concern arises from the fact that the pandemic, and our response to it, has been an emotionally significant challenge for several individuals, and one that may have impacted their lives, worldviews, and social statuses. indeed, if one believes that the world has changed in fundamental ways, it would be difficult to perceive one's own life as having continuity in the same direction as before the event. moreover, shifting social ties may lead individuals to reset their motivations, or at least question the ambitions they once held. with calls for continued self-isolation and social distancing, several individuals are at risk for disconnection from their past selves and motives, and left questioning whether their lives will be continuously discontinuous as a result. the importance of studying derailment comes from its apparent clinical significance, and ease of a recently validated self-report assessment. namely, derailed individuals tend to report greater depressive symptoms, anxiety, and psychological distress, largely distinct from related running head: derailment in a pandemic 3 self and identity constructs (burrow et al., 2020; ratner, mendle, burrow, & thoemmes, 2019) . what makes the concept of derailment unique is also what makes it particularly relevant to the current crisis. namely, derailment captures not only a sense of perceived self-change but also whether individuals feel that their motivations and life directions have been continuous over time. items from the derailment scale (burrow et al., 2020) reflect how many people have felt during recent weeks and months. for instance, most people have probably noticed "how different (they) are now from who (they) used to be," or even are starting to doubt that their lives have "been heading in the same direction for a long time." in addition, several people may no longer feel that their "motivations in life have been the same over time," as they are more focused now on resolving basic needs or completing work-related tasks remotely. as such, derailment may be an especially important indicator of who is in greater need of mental health care in this time of crisis, by helping to identify those individuals most susceptible to trauma rather than resilience following the event. moreover, it is important to note that some symptoms of derailment may be treated even with limited resources. though more malignant forms likely require one-on-one therapy, similar to identity disorders, research has shown that journaling activities at home at least can temporarily help individuals reduce their derailment symptoms (burrow et al., 2020) . given the clear challenges faced by mental health professionals due to the widespread impact of this pandemic, and ongoing public health policies that limit social interaction, derailment may be uniquely positioned as a construct both of great significance for clinicians, and one that may be intervened upon in part without significant inperson care. derailment: conceptualization, measurement, and adjustment correlates of perceived change in self and direction a dimensional taxonomy of perceived characteristics of major life events depression and derailment: a cyclical model of mental illness and perceived identity change covid-19 and mental health: a message that needs to be heard coronavirus disease (covid-19). who.int/emergencies/diseases/novel-coronavirus-2019 key: cord-264300-6qp0ymi2 authors: sutin, angelina r.; luchetti, martina; terracciano, antonio title: has loneliness increased during covid-19? comment on “loneliness: a signature mental health concern in the era of covid-19” date: 2020-07-13 journal: psychiatry res doi: 10.1016/j.psychres.2020.113295 sha: doc_id: 264300 cord_uid: 6qp0ymi2 nan has loneliness increased during covid-19? comment on "loneliness: a signature mental health concern in the era of covid-19" angelina r. sutin*, martina luchetti, and we read the recent letter to the editor by killgore and colleagues (2020) in psychiatry research on loneliness during covid-19 and found it to be a timely issue of broad interest. the authors reported that a national sample of adults aged 18-35 assessed during the pandemic scored significantly higher in loneliness (d=0.48) compared to a sample measured before 2003. there is certainly little doubt that the coronavirus pandemic has caused a great deal of distress that has alarming consequences for mental health. there has been a lot of concern about loneliness in particular because of the implementation of social distancing and stay-at-home orders that have been critical to slow the spread of the virus. while necessary, there have been significant fears about the impact of these measures on loneliness because, by design, they are meant to keep people apart. the killgore findings seem to support these concerns. other studies, however, have not been able to document a similar increase. in a longitudinal study in the united states, for example, participants measured just prior to and then twice during the pandemic found no change in loneliness (luchetti et al., 2020) . that is, participants reported similar average levels of loneliness from before (january-february 2020) to during (mid-march and again in late april 2020) the pandemic. a second study that compared the prevalence of loneliness from 2018 to april 2020 in two national samples came to a similar conclusion: there was not a large increase in loneliness during the stay-at-home orders caused by the pandemic (mcginty et al., 2020) . on the surface, these findings look contradictory. when examining means from different samples, however, the comparison sample is vitally important for what conclusions can be drawn from any differences/similarities found. in this case, killgore and colleagues compared the mean from their national sample (n=1,013) aged 18-35 surveyed in april 2020 to the mean of a sample (n=277) of undergraduate students at a select private college that was published in 2003. there are many differences between the two samples that likely have nothing to do with the pandemic (e.g., age, education, socioeconomic status, setting, year of assessment). in this letter, we compare the loneliness data of killgore and colleagues to a more recent, nationally representative sample to re-evaluate their conclusion. specifically, bruce and colleagues (2019) used the ucla loneliness scale-3, which is the exact same measure used by killgore and colleagues, on a nationally representative sample in 2018. bruce and colleagues reported mean loneliness by age group that allows for more direct comparisons with the sample surveyed during the pandemic than the comparison group used by killgore and colleagues. specifically, killgore and colleagues reported a mean of 43.8 (sd=13.5) in their 18-35-year-old sample. the comparable age groups in bruce and colleagues had a weighted mean of 47.87 (sd=13.76) and 44.92 (sd=13.95) for 18-25-year-olds and 26-34-year-olds, respectively. the means indicated a significant decline in loneliness between 2018 and april 2020 for both age groups (t=7.921, p<.01, d=-0.30 and t=2.231, p=.01, d=-0 .08 for the 18-25 and 26-34 age groups, respectively). this conclusion is in stark contrast to the conclusion in killgore and colleagues. the decline may be due to differences in sampling (e.g., online recruitment versus nationally representative) rather than to an actual decline in loneliness, but overall, from this comparison, there is no evidence of an increase in loneliness during covid-19. we absolutely agree with killgore and colleagues that loneliness is a critical public health concern. loneliness increases risk of mental and physical health burden and decreases life expectancy (hawkley & cacioppo, 2010) . the social distancing and stay-at-home measures that literally keep people apart would seem ripe for tremendous increases in loneliness. but despite the physical distancing, most people may feel emotionally connected because we are all in this together. indeed, there is evidence that people feel more emotional and social support from others than before the pandemic (luchetti et al., 2020) . such support may have helped buffer against the effect of the physical distancing on loneliness. there is little doubt that the pandemic has caused a great deal of distress and that there are pressing mental health problems that must be addressed (mcginty et al., 2020) . resources should be directed at these most critical mental health needs. further, even though there currently is no evidence of a surge in loneliness due to the pandemic, surveillance of loneliness needs to continue. there may be longer-term consequences of social distancing on loneliness that have yet to be detected. the design of most studies of loneliness during the pandemic has relied on responses to online surveys. such methodologies are useful for surveying large numbers of participants efficiently in a short period of time, especially during a pandemic. at the same time, however, these methods are likely to miss populations most vulnerable to the economic and health effects of the pandemic, including families who do not have internet access, rural communities, and individuals in assisted living facilities or nursing homes. more inclusive surveillance is clearly needed. and, yet, despite these caveats and the need for more surveillance, the emerging pattern from this re-analyses of the killgore and colleagues data and others (luchetti et al., 2020; mcginty et al., 2020) is one of resilience rather than harm, at least as far as loneliness is concerned. loneliness in the united states: a 2018 national panel survey of demographic, structural, cognitive, and behavioral characteristics loneliness matters: a theoretical and empirical review of consequences and mechanisms loneliness: a signature mental health concern in the era of covid-19 the trajectory of loneliness in response to covid-19 psychological distress and loneliness reported by us adults angelina r. sutin, phd* martina luchetti, phd antonio terracciano, phd *address correspondence to: angelina.sutin@med.fsu.edu key: cord-287707-ng0ha3vv authors: pal, arghya; gupta, prashant; parmar, arpit; sharma, pawan title: ‘masking’ of the mental state: unintended consequences of personal protective equipment (ppe) on psychiatric clinical practice date: 2020-06-04 journal: psychiatry res doi: 10.1016/j.psychres.2020.113178 sha: doc_id: 287707 cord_uid: ng0ha3vv nan 'masking' of the mental state: unintended consequences of personal protective equipment (ppe) on psychiatric clinical practice "when your face says it all, your mouth waits its turn"this quotation by anthony t. hincks applies as much to psychiatry as to life. the mental state examination (mse) derives significantly from simple observation of someone"s facial expressions and body language, in addition to clinical questions. but, the current covid-19 pandemic has necessitated certain changes in the way mse is conducted, e.g., face masks, alcohol hand-rubs, social distancing, etc., and these changes may be here to stay ("when and how to use masks," n.d.). in this paper, we have highlighted some of the major issues which are likely to arise during mse and psychiatric interviews with the pandemic-related precautions in place, and the need to find alternative strategies to deal with these problems. the use of masks hampers the observation of facial expressions which is very important for any mse. the fact that whether someone is smiling, frowning,has flat expressions, or is looking around out of suspicion or confusion, gives significant clues into their mental state (martin, 1990 ). this may be even more difficult in settings where the use of other protective gears like face-shield and goggles is necessary (mistry et al., 2009) . similar to problems in observing expressions, we are likely to miss orofacial movement disorders such as tics or tardive dyskinesias, subtle mumbling which may occur as a part of hallucinatory behaviour in psychosis andsubstance use-related signse.g. tobacco (oral mucosal changes), opioids (pupillary constriction/dilation, lacrimation)or cannabis (conjunctival injection). also, due to the smell of alcohol hand-rubs, psychiatrists may miss on subtle smell cues such as body odour arising out of poor self-hygiene and smell of substances like alcohol and cannabis which might suggest intoxication. furthermore, making eye contact and establishing a rapport is challenging given the distraction of the ppe and the "non-humanly" feeling it gives. e.g., ppe might accentuate the suspiciousness in patients who have paranoia, the new smells and appearances may be extremely difficult to cope with for patients with autism spectrum disorders, patients having depression might require a gentle human touch and support during an interview which becomes near impossible with ppe and social distancing, it might be very challenging to provide reorientation to patients having delirium, or memory cues to those having dementia when they cannot see the faces of those around them, etc. speaking through masks can muffle the speech, which hurdles the coherence and volume of speech. in disorders like severe depression and negative symptom schizophrenia, where the patient might be barely audible in usual circumstances, masks might make conversations near impossible (priebe et al., 2011) . also, because of the difficult conversation, the therapist and patient might have to frequently ask each other to repeat what they are saying, thus making the conversations more tedious and time consuming. as mentioned above, there can be hurdles in observing expressions in presence of ppe. this makes it extremely difficult to estimate the objective affect, range of emotion and presence of reactivity to stimuli, which are important markers for some mental health conditions. eliciting thought and perceptual abnormalities often requires detailed phenomenological explorations. the difficulties in understanding speech, as mentioned above, make this task very challenging., e.g., muffled speech makes it difficult to pick formal thought disorders and ineffective conversations make it difficult to understand the phenomenological content of delusions and hallucinations. apart from the difficulties in conducting mse, ppe may also pose a barrier to observe some clinical signs which are as important to psychiatry as for other medical disciplines, e.g., injuries, pallor, icterus, cyanosis, etc. inability to pick up signs of potentially life-threatening conditions such as pupillary constriction in opioid overdose, tremors in lithium toxicity and dehydration in catatonia, can prove to be disastrous. in such scenarios, psychiatrists might find themselves in ethical dilemmas where they might be tempted to remove their own ppes or ask the patients to remove theirs, for unimpeded mses and clinical interviews, potentially putting their own or the patients" health and life at risk. there seems to be no easy answer to this (mehta et al., 2020) . potential strategies to bypass some of these problems may include the creation of a transparent physical barrier between the psychiatrist and the patient or teleconsultations, but they may have their own shortcomings.ultimately, it boils down to the quintessential comparison of risk vs benefit of such practices. it would be highly beneficial for psychiatrists and patients alike if the national or international psychiatric bodies can prepare guidelines while weighing all the pros and cons, to conduct interviews and mses during the current pandemic. international psychiatry fellow, barnet, enfield and haringey mental health (nhs) trust, london, uk 3. national consultant (harm reduction) clinical methods: the history, physical, and laboratory examinations. butterworths the "mind" behind the "mask": assessing mental states and creating therapeutic alliance amidst covid-19 veiled communication: is uncovering necessary for psychiatric assessment? good communication in psychiatry -a conceptual review when and how to use masks none key: cord-258133-zsweppku authors: fischer, m.; coogan, a.n.; faltraco, f.; thome, j. title: covid-19 paranoia in a patient suffering from schizophrenic psychosis – a case report date: 2020-04-17 journal: psychiatry res doi: 10.1016/j.psychres.2020.113001 sha: doc_id: 258133 cord_uid: zsweppku nan the covid-19 pandemic affects mental health, both in healthcare settings and broader society. fear responses in both the uninfected and infected may reach psychopathological levels that require psychiatric interventions (duan and zhu, 2020) , and physicians and mental health professionals may have particularly high need for psychological support in the case of development of stress-related disorders (chen et al., 2020 ). an area of key concern is the potential of the psychological context of the pandemic to exacerbate existing psychiatric conditions and influence the manifestation of their symptomatology. here we report the case of a patient with schizophrenia presenting with covd-19related delusions and hallucinations, illustrating the potential of covid-19 to precipitate entry into a psychotic phase and impact symptom manifestation. we report a 43-year-old, unmarried male patient who was brought to our emergency department by his father during the early phase of the covid-19 crisis in germany (march 17th 2020). his psychiatrist referred him after prescribing paliperidone depot trevicta® (525 mg, dose increased from 350 mg). admission to our hospital was deemed necessary because for approximately one week prior the patient had been hearing his neighbours' voices (both males and females) blaming him, as a former ambulanceman, for not taking sufficient care of his parents who could have died of a covid-19. the voices also claimed that all of the neighbours could also have covid-19 as a result of his negligence. our patient recognized the voices as hallucinations which could be a sign of worsening of his paranoid psychosis, which had been first diagnosed in 2011. nevertheless, obeying the voices he went to his parents' house in the middle of the night to check if they were alive, but ultimately decided not to enter the house. he also believed that he was being observed by cameras at his home and he personally expected to have immunity to covid-19 after already being infected by a chinese message through a whatsapp group. physical examination revealed no pathological findings. laboratory testing indicated slightly increased mean corpuscular hemoglobin (mch) and liver enzymes aspartate aminotransferase (ast/got) and alanine aminotransferase (alt/gpt), possibly as a result of alcohol use in the past or a medication side effect. during two previous hospitalisations in 2011 and 2019 the patient had presented with similar symptoms, including voices commenting on his behavior and reporting being observed by cameras in our clinics, and he was diagnosed with acute polymorphic psychotic disorder (icd-10: f23.0) and paranoid psychosis (icd-10: f20.0), respectively. during these previous episodes remission was achieved following treatment with olanzapine. since 2019 he had been regularly taking paliperidone depot every three months (350 mg). at admission the patient was experiencing acoustic hallucinations, was very tense and anxious with a slightly depressed mood, but was also relatively coherent. positive and negative syndrome scale (panss) assessment two days later confirmed medium symptom severity (total score: 75/210; positive scale: 18/49, negative scale: 19/49; general psychopathology scale: 38/112). the wisconsin card sorting test revealed deficits in the recognition of concepts, change of concepts and flexibility in attention. during inpatient treatment in our department we initiated olanzapine 25 mg/day and lorazepam (up to 2 mg/day), and this in addition to the paliperidone depot, led to subsiding of symptoms: voice hearing was reported as much less frequent and more in the background before completely disappearing. the patient also reported that he no longer believed that his family and neighbours were infected, and this resulted in reductions of his anxiety and tension. the successful treatment of the covid-19-related hallucinations leads us to speculate that a decline in paliperidone serum level towards the end of the three months treatment period may have contributed to the onset of the described symptoms. this case report shows the impact of the covid-19 crisis on the psychopathology of a patient with paranoid psychosis leading to the outbreak of a psychotic phase with paranoid-hallucinatoric experiencing and unrealistic expectations and concerns. this is, to the best of our knowledge, the first report of a covid-19-related paranoid processing in a psychosis patient. it is reasonable to expect that media coverage of exceptional circumstances will influence the content of delusional thoughts, especially in crises like infectious disease pandemics or after assassinations. however, the number of studies addressing such issues is very limited; one such study carried out during the 2009 swine influenza pandemic indicated that patients with schizophrenia and a high level of predicted fear tended to judge their own risk of infection as higher (maguire et al., 2019a ). an interesting aspect of the current case is that in a highly interconnected world, our patient assumed a chinese whatsapp message had infected him. moreover, he was more concerned about others than himself, a manifestation possibly influenced by his former role as an ambulanceman. this observation may be in line with the previous reports that higher levels of concurrent anxiety in patients with schizophrenia correlated with lower perception of personal risk of infection with swine flu, although the reason for this effect is unclear (maguire et al., 2019a) . patients with schizophrenia have also been shown to be less willing to get vaccinated and to adhere to social distancing during an influenza pandemic (maguire et al., 2019b) . our patient reported trying to spend more time at home because of covid-19, but did not adopt other protective measures such as hand washing or wearing a face mask. overall, the current case report illustrates the potential for the psychological context of the covid-19 emergency to influence emergence and manifestations of symptoms of psychosis, and indicates that measured, balanced and responsible reporting of the covid-19 crisis in the media will be important to minimize the risk of overreactions in at risk persons and to avoid entry into psychotic episodes. the reported patient agreed in the publication of this report. all steps were conducted in accordance with the regulations of our local university ethical committee (ethikkommission an der medizinischen fakultät der universität rostock, st.-georg-str. 108, 18055 rostock, registriernummer a 2020-0077) and the declaration of helsinki. no funding was received for this work. mental health care for medical staff in china during the covid-19 outbreak psychological interventions for people affected by the covid-19 epidemic a sense of dread: affect and risk perception in people with schizophrenia during an influenza pandemic nothing to sneeze at -uptake of protective measures against an influenza pandemic by people with schizophrenia: willingness and perceived barriers all authors read and approved the final manuscript and contributed equally to it. the authors declare that they have no competing interests. key: cord-273794-gvjwvabm authors: palomar-ciria, nora; blanco del valle, patricia; hernández-las heras, miguel ángel; martínez-gallardo, ricardo title: schizophrenia and covid-19 delirium. date: 2020-05-27 journal: psychiatry res doi: 10.1016/j.psychres.2020.113137 sha: doc_id: 273794 cord_uid: gvjwvabm since its outbreak, coronavirus disease 2019 has been producing atypical manifestations aside from fever, coughing and dysnea. one of the most common is delirium, which, however, is highly overlooked. this has consequences in the treatment of patients and also may lead to underdiagnosing the infection. in this work, we present the case of a man diagnosed with schizophrenia, who had been stable for more than 20 years and that presented with an atypical picture of psychotic and confusional symptoms related to covid-19 infection. since its outbreak, coronavirus disease 2019 has been producing atypical manifestations aside from fever, coughing and dysnea. one of the most common is delirium, which, however, is highly overlooked. this has consequences in the treatment of patients and also may lead to underdiagnosing the infection. in this work, we present the case of a man diagnosed with schizophrenia, who had been stable for more than 20 years and that presented with an atypical picture of psychotic and confusional symptoms related to covid-19 infection. schizophrenia; delirium; covid-19; coronavirus. coronavirus disease 19 (covid-19) was declared a pandemic by the world health organization (who) in march 2020. since the outbreak, atypical presentations such as delirium, confusion and stupor have been developing (alkeridy et al., 2020) . delirium has been found highly common in hospitalized patients, due to factors related to this virus directly affecting cns. delirium is considered a marker of encephalopathy and worse prognosis (kotfis et al., 2020) and its prevention and recognition may help to identify underlying infection in otherwise asymptomatic patients (alkeridy et al., 2020) . covid-19 has already had a great impact in the general population worldwide and patients diagnosed with schizophrenia are at greater risk of infection and its consequences, due to difficulties following preventive rules and the presence of other medical comorbidities. moreover, infected patients with schizophrenia may have more severe symptoms compared to others. these patients also may be impeded their access to treatment and intervention, rising the risk of relapse (fonseca et al., 2020) . despite this conditions, patients with severe mental disorders have widely been overlooked (li and zhang, 2020) . we present mr. s., a 65 year-old diagnosed with stable schizophrenia for more than 20 years, treated with amisulpride 200 mg per day until august 2019, when he discontinued it voluntarily. he suffers hypertension and sleep apnea syndrome treated with cpap. on march 27 th , 2020, mr. s. was admitted to the psychiatric in-patients unit due to bizarre behavior, perplexity, incoherent speech that had been occurring for 20 days approximately. his espouse explained that he would be angry because somebody had insulted him and would wander naked at home. she reckoned the situation was triggered by the alarm estate and confinement in spain, that had started on march 14 th . at first, mr. s. was agitated, aggressive, confused and disoriented in time and did not consent to take oral medicationamisulpride. he presented with global insomnia, disorganized behavior and discourse, echolalia. he also started to show some loss in basic skills, such as feeding himself and getting dressed. some amnesic fails were observed though they soon recovered. amisulpride was augmented to maximum dosage to 2400 mg per day. on april 5 th , he was tested for covid-19 following the novel hospital protocol. pcr resulted negative. suspecting organic conditions underlying and the scarce response to treatment, we requested a cephalic ct scanpatched hypodensities in deep white matter suggestive of leukoencephalopathy of small vesselsand a cerebral mridilatation of ventricular system and subarachnoid spaces according to patient´s age. by may, we suspected a confusional syndrome in the context of the covid-19 pandemic and antibodies were requested, with positive results for both igg and igm. a pcr was then carried out, resulting negative. afterwards, melatonine up to 7 mg per day and haloperidol at low doses (2 mg per day) were added. amisulpride was adjusted to 600 mg per day. currently, mr. s. has normalized speech and behavior and has regained basic autonomous abilities and temporal orientation. improvement is slow but steady. delirium is known to be common in patients infected with covid-19. however, it remains overlooked and it is not yet included in guidance for diagnosis, which would have great impact for patients and would lead to underdetection of coronavirus disease. on top on that, patients with schizophrenia are usually overlooked though that disorder may represent a greater risk of medical comorbidities and increased risk of covid-19 infection, even when hospitalized. additionally, viral exposure, medical treatment for the coronavirus infection and psychosocial distress have been associated with psychosis (brown et al., 2020) . in our case, it is difficult to determine whether mr. s. acquired coronavirus disease prior admission or during hospitalization. he did not present with organic symptoms such as fever, coughing or similar. what seems feasible is that a mild psychotic relapse has been worsen by this infection, producing confusional symptomatology as an atypical presentation. furthermore, we wonder that even if it is a mild infection as it did not require intensive care medicine, its severity lies on the basal psychiatric condition. awareness for non-specific symptoms is granted, especially in vulnerable groups, where clinical management can be challenging (brown et al., 2020) . not only are medical aspects of this virus important, but also research on the psychiatric factors should be warranted, as it is well known that this virus is highly neurotropic and psychiatric patients, a population at risk. hence, clinicians and families must keep alert on both physical and psychiatric symptoms, in order to detect the infection in early stages (fonseca et al., 2020) . none. a unique presentation of delirium in a patient with otherwise asymptomatic covid-19 the potential impact of covid-19 on psychosis: a rapid review of contemporary epidemic and pandemic research schizophrenia and covid-19: risks and recommendations covid-19: icu delirium management during sars-cov-2 pandemic mental healthcare for psychiatric inpatients during the covid-19 epidemic key: cord-293986-skp6tiun authors: millard, hun; wilson, cynthia; fortunati, frank; li, luming title: covid-19 psychiatric patients: impact of variability in testing on length of hospital stay and disposition back to congregate care settings date: 2020-07-24 journal: psychiatry res doi: 10.1016/j.psychres.2020.113324 sha: doc_id: 293986 cord_uid: skp6tiun 184• coronavirus (covid) impact on hospital psychiatric inpatient units; 184• testing versus symptom based strategies that impact psychiatric inpatient treatment; 184• challenges in discharging medically and psychiatrically stable covid patients back to their congregate care living facilities. coronavirus disease 2019 (covid) is a highly contagious viral illness that can lead to severe acute respiratory syndrome and fatality. this pandemic has changed inpatient hospital treatment at every level of care and significantly impacted our daily lives (griffin et al., 2020) . while frontline healthcare workers have provided heroic treatment to those seriously ill from covid, clinical care has also been altered for a subset of hospital patients who test positive but are asymptomatic. the authors here explore more specifically the challenges that have emerged with inpatient psychiatric patients who have asymptomatic covid and its impact on disposition (bojdani et al., 2020) . there has been a growing number of patients who live in community congregate care settings who face a unique barrier to discharge even after reaching psychiatric stability because of their covid positive status. due to variability in testing and reluctance of congregate care facilities to accept covid patients back into the community, the authors experienced many cases in which hospital discharge was delayed anywhere from 7 to 47 days. thus, on top of social distancing, individuals who are unable to return home face challenges of further isolation, anxiety, and perceived rejection while awaiting covid results in the hospital. covid testing has presented unique challenges to inpatient psychiatric care. notably, testing timeframes are important. some covid tests are processed in 2-, 4-, 6-, 24-hour timelines and for those that are send-out tests the processing time can be longer and lead to increased time that a patient spends as a "person under investigation." additionally, testing results can be variable from having cases with a wide combinatorics on positive, negative, and inconclusive results. for example, a patient may initially be negative, and then upon re-testing the patient may be positive. however, the lag time may have been several days, and during this time, other patients and staff could be infected. in addition, a patient may test positive and remain so for well over 4 weeks even though they are no longer infectious. recently, the cdc has issued guidelines on both testing-based and symptom-based strategies for discontinuing isolation precautions (cdc, 2020). literature suggests that an individual may carry viral rna for multiple weeks after the virus is no longer replicating . thus, there have been recent recommendations to use a guideline for 10 days without symptoms to determine when to stop isolation precautions. due to initial recommendations for negative tests many community agencies are concerned about the risk for infectious spread and request two negative tests with varying intervals of time in between. this can present challenges to disposition for psychiatric patients who may be stable for discharge yet need to wait for two negative tests -prolonging hospital length of stay. the new challenges of the covid pandemic has forced hospitals to adapt patient care, especially in congregate psychiatric settings. there remains many lessons and refinement of processes in the way we treat our patients both in and out of the hospital. stemming from a lack of clear protocols and fears of spreading covid, individuals with comorbid mental health and asymptomatic covid illness have not been easily able to return to their community based congregate care facilities. guidelines and criteria for returning to individual residential and group homes have been inconsistent and typically more stringent than updated cdc recommendations. this is in part due to high rates of spread and mortality in congregate living situations and in part due to miseducation and fear. stable psychiatric patients are experiencing longer psychiatric inpatient lengths of stay, even when continued hospitalization is no longer the least restrictive environment. in addition, variability in testing results has a significant impact on discharge planning. although testing variability has been explored in the literature, we report here the direct impact of testing variability on patient care in inpatient psychiatry (zou et al., 2020) . further studies are needed to assess if viral loading and testing profiles are different for those with psychiatric illness. subpopulation analyses are needed to assess mechanistically easier testing methods for mental health patients, as some psychiatric patients are experiencing inconclusive or inaccurate results. early reports on a saliva test for covid may be helpful as it comes more commercially available. an important recommendation for clinical care is for community based congregate care facilities to adopt cdc guidelines in a timely manner to minimize delays in care, such as switching from a test-based strategy to a symptom-based strategy (cdc, 2020) . this requires close coordination between community and inpatient psychiatric facility leaders, and decisionmaking to adopt new recommendations. to further facilitate as smooth a transition to a congregate care setting, we found that communication with patient and families and outpatient treatment teams is key. for example, setting up weekly meetings to debrief events and progress and provide psychoeducation to the primary outpatient clinicians and direct care staff of community facilities has been advantageous. education on updated recommendations from the cdc may also be helpful in alleviating anxiety that facilities have of accepting patients back following a covid diagnosis. our team was able to ask infectious disease experts to join such collaborative care discussions to provide further assurance and support recommendations for discharge. further, our inpatient unit modeled these cdc recommendations by integrating some asymptomatic covid patients back to non-covid psychiatric units after completing appropriate quarantine periods. these patients were successfully integrated into regular therapeutic milieu treatment with non-covid peers and had no symptoms at the time of discharge nor did this lead to further infectious spread. this move helped to illustrate the hospital's confidence in mixing asymptomatic covid patients back into the community and importantly the individual patient had greater access to more socially normative inpatient psychiatric treatment. beyond individual provider or unit level patient advocacy, it would be advantageous for hospital administrative leadership to engage with community program leaders to create a space of open dialogue about shared goals around best practices of patient care both in the hospital and in community congregate care facilities. symptom-based strategy to discontinue isolation for persons with covid-19 hospital preparedness for covid-19: a practical guide from a critical care perspective temporal dynamics in viral shedding and transmissibility of covid-19 sars-cov-2 viral load in upper respiratory specimens of infected patients nothing to declare. the authors have no declaration of competing interests and no disclosures. key: cord-276423-8rwmrl0l authors: mota, pedro title: avoiding a new epidemic during a pandemic: the importance of assessing the risk of substance use disorders in the covid-19 era. date: 2020-05-28 journal: psychiatry res doi: 10.1016/j.psychres.2020.113142 sha: doc_id: 276423 cord_uid: 8rwmrl0l nan on march 11, 2020, the world health organization classified the public health emergency caused by covid-19 as a pandemic, causing significant changes in people's daily lives and a devastating impact on the economy, accompanied by a profound overhaul of social structures and health systems. from its expected major impact on mental health, social distance measures imposed worldwide are themselves risk factors for different mental health problems, including suicide and self-harm, alcohol and substance misuse, gambling and domestic/child abuse. since quarantined people may experience boredom, loneliness, anger, depression, anxiety, despair and insomnia, providers should be alert to potential increases in substance use to alleviate these negative feelings, particularly among vulnerable patients like those with a substance use disorder (sud). globally, suds are estimated to have a prevalence of 100.4 million persons for alcohol, 22.1 million for cannabis and 26.8 million for opioids (gbd 2016 alcohol and drug use collaborators, 2018) , and social and mental health support is crucial for people trying to recover from sud, whereas social isolation is a risk factor for relapse. as frequently documented, housing instability as well as reduced access to health care and recovery support services pose an additional challenge in these populations. compared to the general population, people with substance use disorders are more likely to have a higher burden of comorbid medical conditions, and it is now well known that people who habitually smoke or vape tobacco and/or cannabis are at particular risk of experiencing more unfavorable outcomes due to the respiratory and pulmonary effects of sars-cov2 (berlin, et al., 2020) . immunocompromised individuals (like those due to hiv infection) also are in increased risk, and a considerable percentage of this population inject drugs. the withdrawal symptoms triggered during social confinement can also end up compromising these measures imposed by governments, leading individuals to leave their homes in search of drugs on the streets, potentially increasing their exposure to the virus. being an easily accessible substance, alcohol consumption is often used to cope with negative emotions. present times of uncertainty may lead to an increase in alcohol misuse, relapse and development of alcohol use disorder. this can lead to physical dependence and a drastic restriction on access to alcohol can lead to life-threatening withdrawal symptoms, as well as an increased risk for domestic violence. alongside isolation itself, depression and alcohol consumption are risk factors for suicide, which may also be triggered by unemployment and other social/financial stressors. in addition, excessive alcohol consumption may lead to a weakened immune system, increasing a person's susceptibility to pneumonia (sarkar, et al., 2015) , making this population particularly vulnerable to covid-19. in order to also deal with anxiety and insomnia during this period, the consumption of other drugs, such as benzodiazepines and cannabis is expected to occur. although benzodiazepines are legal substances usually prescribed by doctors, they represent a potential for abuse, and their excessive consumption can often go unnoticed. the consumption of these legal drugs is particularly prevalent among elderly patients, who represent the main age-risk group for covid-19 infection, and it is important to note that the prevalence of sud in this population has been increasing globally (kuerbis, et al., 2014) . cannabis abuse has been proposed as a precipitant of psychotic episodes in people with schizophrenia and capable of anticipating the onset of disease development. potentially aggravated by its chronic use, the socalled cannabis amotivational syndrome refers to lack of motivation, decline in functioning levels and apathy, a condition with a predominance of negative symptoms, which culminates in a state of neglect and divestment in the individual itself. drug treatment for opioid use disorders can be immediately effective and life-saving, and is usually provided in an outpatient setting. since it is a therapy highly regulated by health authorities, people with opioid use disorders may face even greater challenges obtaining opioid agonist treatment, which should be considered an essential treatment during the covid-19 pandemic (world health organization, 2020). greater flexibility in dispensing take-home medication, such as providing more than one dose of methadone at a time due to restrictions of movement, in combination with isolated consumption, increases vulnerability to relapse and overdose, since there might not be any observers who can administer naloxone to reverse them. there is also evidence of increased burden of respiratory diseases in people who use illicit opioids, making this is group especially vulnerable to the pandemic threat, as there is an increased risk of overdose, since these substances can depress breathing. in some patients, particularly those with personality disorders, substance use reflects the difficulty in processing feelings of emptiness and abandonment (which may be further aggravated due to quarantine and imposed social isolation), or even the search for a toxic state that promotes an internal elevation of mood, promoting greater harmony and pleasure. these individuals present a behavioral functioning pattern determined by instability and an intensely disruptive psychological conformation, with an underlying hyper-responsiveness to stress. the current pandemic crisis has also led to the interruption of psychotherapeutic support in this population, which may precipitate greater destabilization among these patients on a daily basis, leading to acting-out behaviors, with an increased frequency of drug intoxications and substance consumption. people who started using drugs as a way to help with their suffering caused by the changes imposed by the pandemic, as well as those who already used them or accessed substance abuse treatment services may be particularly at risk during the current covid-19 pandemic. usually, these end up constituting marginalized groups, despite being present in countries of all incomes, so it is urgent that they be taken into account in public health strategies. thus, considering the worldwide reorganization of mental health services, addiction care must be reinforced, instead of postponed, so clinicians could be aware of signs of substance misuse in these populations, considering the levels of additional stress they may be experiencing. for those with substance use disorders, changes in the ability to access substances and their treatments can precipitate new crises. covid-19 and smoking the global burden of disease attributable to alcohol and drug use in 195 countries and territories, 1990-2016: a systematic analysis for the global burden of disease study 2016. the lancet substance abuse among older adults alcohol and the immune system who model lists of essential medicines key: cord-270570-wttom8eh authors: killgore, william d.s.; cloonan, sara a.; taylor, emily c.; dailey, natalie s. title: loneliness: a signature mental health concern in the era of covid-19 date: 2020-05-23 journal: psychiatry res doi: 10.1016/j.psychres.2020.113117 sha: doc_id: 270570 cord_uid: wttom8eh in response to the covid-19 pandemic, most communities in the united states imposed stay-at-home orders to mitigate the spread of the novel coronavirus, potentially leading to chronic social isolation. during the third week of shelter-in-place guidelines, 1,013 u.s. adults completed the ucla loneliness scale-3 and public health questionnaire (phq-9). loneliness was elevated, with 43% of respondents scoring above published cutoffs, and was strongly associated with greater depression and suicidal ideation. loneliness is a critical public health concern that must be considered during the social isolation efforts to combat the pandemic. the rapid emergence of covid-19 and the collective efforts to minimize its spread have severely disrupted the normal lives of much of the world's population. to contain the spread of covid-19, most people living in the united states have been advised to stay at home and shelter-in-place since the middle of march, 2020. throughout this "lockdown" period, most people have been encouraged to work from home if possible, and avoid leaving their residence except for necessities. if it is essential to venture outside, people have been urged to wear face masks, avoid gatherings of people, and maintain physical distance of 6-feet or more from others. even more severe social isolation and quarantine restrictions have been imposed for those who have potentially come into contact with the virus, with such individuals advised to completely self-isolate for at least two weeks. for the first time in many people's lives, they are experiencing an unwanted and prolonged separation from a vital, and deeply human, aspect of their existence. they are alone-with no certain end to the isolation in view. we hypothesized that the prolonged social isolation enacted during the covid-19 pandemic may increase feelings of loneliness, a key contributor to mental health problems such as depression and suicide (stickley and koyanagi, 2016) . to assess the impact of current social isolation on loneliness and mental health, we administered the ucla loneliness scale-3 (russell, 1996) , a validated metric of the construct of loneliness, and the patient health questionnaire-9 (phq-9) (kroenke et al., 2001) , a widely used screening measure for depression, to a nationally representative sample of 1,013 (18-35 years old; 567 females; 446 males) english speaking u.s. adults. the scales were administered during the third week of the national emergency concerning the novel coronavirus and the stay-at-home orders enacted by most states (i.e., april 9-10, 2020). participants were sampled from all 50 states, proportional to state population. written informed consent was obtained prior to participation and the study protocol was approved by the institutional review board of the university of arizona. for loneliness, mean scores were compared with prior published data to evaluate severity, and were further dichotomized into loneliness groups based on the published cutoff score of ≥47 (morahanmartin and schumacher, 2003) . for the phq-9, mean depression scores were calculated according to the standard instructions. depression scores and the score from the single suicidal ideation item (item 9) were compared between loneliness groups using analysis of covariance (ancova), with age and sex as covariates. overall, 93.6% of the sample reported that, at the time of the assessment, they were "sheltering-in-place", and 61.5% endorsed feeling "socially isolated much of the time." the mean loneliness scale score in the current sample (m=43.8 ± 13.5) was significantly higher than reported in prior work (m=38.4 ± 13.5; t 1287 =6.31, p<.0001; d=0.48), with 43% of respondents exceeding the cutoff for high loneliness (morahanmartin and schumacher, 2003) . lonely individuals (m=10.47 ± 6.40) were significantly more depressed than the nonlonely (m=4.45 ± 4.74; f 1,997 =299.49, p<.00001, partial η 2 = .23), with 54.7% of lonely participants meeting clinically significant criteria for moderate to severe depression compared to 15.3% of non-lonely participants (or: 6.90, 95% ci: 5.10-9.33; p<.00001). moreover, lonely individuals (m=0.55 ± 0.88) scored significantly higher than non-lonely (m=0.07 ± 0.36) respondents on the phq-9 suicidal ideation item (f 1,997 =138.13, p<.00001, partial η 2 = .12), with 34.9% of lonely respondents endorsing some level of suicidal ideation compared to 4.5% of non-lonely participants (or: 10.97, 95% ci: 7.04-17.11; p<.00001). in the midst of the mandates to self-isolate during the covid-19 pandemic, a large proportion of the population is experiencing a significant surge in self-reported loneliness. while causation cannot be inferred from cross-sectional data, the present findings are consistent with the notion that the prolonged stay-at-home efforts enacted during the pandemic are likely severely increasing loneliness and social disconnection among many people. this is concerning, as loneliness has been associated with a wide range of mental health problems, interpersonal issues, substance use, and physical health conditions, including cognitive decline, and significantly elevated morbidity and mortality (ingram et al., 2020) . we found that greater loneliness in the present sample was associated with elevated depression and higher suicidal ideation on a standard clinical screening instrument. the observed effect sizes are large, suggesting that they are likely to have a tangible and meaningful impact when considered at the population level. the potential for elevated suicide risk during the pandemic should be taken seriously by healthcare providers, particularly given the huge economic stresses produced by recent job losses and furloughs. awareness of the problem is the first step. the public needs to understand that increased loneliness is an expected and probable consequence of current self-isolation measures, and efforts need to be directed at minimizing stigma that may surround those who admit they feel lonely. we recommend that loneliness and perceived social isolation be routinely assessed during clinical encounters. further, greater considerations of the mental health needs of the populace (including perceived social isolation and loneliness) must be incorporated into longer-term public health responses to covid-19. efforts need to be directed toward finding novel and creative approaches for maintaining social connectedness while still following public health guidelines for minimizing virus transmission. loneliness among people with substance use problems: a narrative systematic review the phq-9: validity of a brief depression severity measure loneliness and social uses of the internet ucla loneliness scale (version 3): reliability, validity, and factor structure loneliness, common mental disorders and suicidal behavior: findings from a general population survey none. none. key: cord-286222-8gfo2c87 authors: chandra, dr prabha s; shiva, dr lakshmi; nagendrappa, dr sachin; ganjekar, dr sundarnag; thippeswamy, dr harish title: covid 19 related psychosis as an interface of fears, socio-cultural issues and vulnerabilitycase report of two women from india date: 2020-05-27 journal: psychiatry res doi: 10.1016/j.psychres.2020.113136 sha: doc_id: 286222 cord_uid: 8gfo2c87 nan type of manuscript: correspondence (letter to the editor) title: covid 19 related psychosis as an interface of fears, socio-cultural issues and vulnerability-case report of two women from india authors: prabha s chandra a *, lakshmi shiva a , sachin nagendrappa a , sundarnag ganjekar a ,harish thippeswamy a affiliations: a.national institute of mental health and neurosciences, bengaluru-560029, india there have been reports of heightened anxiety about covid 19 leading to psychosis and related psychopathology (brown et al., 2020; d rentero et al., 2020; vald´es-florido et al., 2020) . increased levels of anxiety may be related to factors such as fears of the infection, social isolation linked to lockdown or because of the economic and occupational impact of the pandemic. women who are vulnerable either due to personality factors, a family history or those in the perinatal period may be at risk for psychotic symptoms precipitated by high levels of covid related anxiety (wu et al., 2020) . we report two women who presented to the national institute of mental health and neuro sciences, an academic psychiatric centre in bangalore, india. for both women, this was a first episode of psychosis with psychopathology relating to covid 19. informed consent for reporting was obtained from both women. ms. r a 34-year old married housekeeper with two children, who had migrated recently to the city, presented with a two day history of being extremely fearful that she would get covid 19 infection and her family and she would die. this started on the day of a major hindu festival immediately after the lockdown was announced in india. ms. r had been looking forward to celebrating the festival with her family in the village and more importantly visiting a local temple for blessings as per tradition. due to the lockdown, travel had to be cancelled and this made her extremely distressed. following this she lost sleep and was continuously watching news about the spread and deaths related to covid 19. she was convinced that the family deity would curse them with covid infection because they had failed to do the annual ritual and if found covid positive, the police would take her away from her family. the next day she started hearing voices that she and her family would die. ms. r was known to have an anxious personality and her father had experienced a brief psychotic episode. her husband had been furloughed because of the lockdown. her physical examination was normal and she did not have any cognitive deficits. on mental status examination, she appeared extremely fearful and would often burst into tears. she kept mentioning that the prime minister of india (who had appeared on tv a day earlier) had sent the doctors and he would also arrive in a plane to save her. she was diagnosed with acute polymorphic psychosis (icd 10)(world health organization, 2004). the psychotic symptoms improved with a week of risperidone 4 mg and low dose of clonazepam 0.25 mg. however, she continued to report anxiety and constant rumination about covid infection for which she was started on escitalopram 10 mg a day, provided reassurance and taught simple cognitive techniques to deal with anxiety with which she improved considerably. ms. s a 24-year old married woman from a rural background consulted us when she was two months postpartum with her first child. she had no family or past history of psychiatric disorder. during pregnancy she had been a bit anxious because of her hypothyroidism and hypertension and also related to pressure from in-laws for a male child. ms. s delivered a baby girl through caesarean section and on the third day of birth the infant developed sepsis, hyperbilirubinemia and seizures necessitating a neonatal icu admission. following this event, the patient became agitated and began talking irrelevantly. following treatment with olanzapine 15 mg/day she remained well for the next one and half months. with the covid 19 outbreak in india and messages about handwashing and hygiene being circulated in the media, ms. s. became excessively anxious about contracting covid 19. criticism by relatives about having a female baby and her inadequacy as a mother made her feel worse. sertraline 50 mg/d was added by her psychiatrist and olanzapine was stopped. however, her condition worsened and she presented to our mother baby unit (mbu), with agitation, crying spells, excessive anxiety, persecutory delusions and overvalued ideas that she had contracted covid 19 infection and was spreading it to her infant. this resulted in her refusing to breastfeed for fear of spreading the infection to the infant. at presentation, she also had catatonic symptoms of mutism and staring. her physical examination was normal. an icd 10 diagnosis of acute polymorphic psychosis, postpartum onset was made. blood investigations and ct brain were normal and her rt-pcr test for covid 19 was negative. she was started on lorazepam for catatonia and olanzapine up to 20 mg daily with which her psychotic symptoms resolved. however, anxiety symptoms and fear about covid 19 persisted. low dose escitalopram was added and in the mbu she was provided support with infant care and breastfeeding, with which she showed improvement. the women described above with a first episode of psychosis demonstrate how several factors may act in confluence to increase stress levels in the covid 19 situation. fears are related both to the infection and its social implications, which include stigma and social exclusion related to quarantine. a lockdown imposes social isolation and also loss of familiar rituals and family traditions which may hold much meaning in some cultures. covid 19 infection is no longer just a medical condition but is surfacing as a social malady that creates immense stress for those who are vulnerable and feel unsupported. we know that the postpartum is a highly vulnerable period for psychosis and infant related delusions are not uncommon (chandra et al., 2006) . however, to our knowledge this is the first report of covid related psychopathology in a woman with postpartum psychosis. this report emphasizes the need to understand the confluence of vulnerability factors (migrating to the city, postpartum period, anxious personality, family history) and precipitating factors (lockdown, media reports, stigma and fears of covid 19 infection, lack of familiar rituals, economic stress) in the etiology of psychosis. these observations emphasize the need for developing preventive strategies for vulnerable groups and developing support systems during this crisis as steps to prevent mental illness related to covid 19. the potential impact of covid-19 on psychosis : a rapid review of contemporary epidemic and pandemic research delusions related to infant and their association with mother -infant interactions in postpartum psychotic disorders. arch womens ment heal new-onset psychosis in covid-19 pandemic: a case series in madrid reactive psychoses in the context of the covid-19 pandemic: clinical perspectives from a case series international statistical classification of diseases and related health problems(icd-10) perinatal depressive and anxiety symptoms of pregnant women along with covid-19 outbreak in china we have no acknowledgements to make. we declare that we have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. key: cord-315200-4texyck8 authors: banerjee, dr debanjan title: the other side of covid-19: impact on obsessive compulsive disorder (ocd) and hoarding date: 2020-04-11 journal: psychiatry res doi: 10.1016/j.psychres.2020.112966 sha: doc_id: 315200 cord_uid: 4texyck8 nan 4 the prompting of family to ensure strict hygienic measures and vice versa. 5 the constant loading of information from various media sources about possibility of the virus to stay active on various inanimate surfaces, hence adding to the thoughts of contamination. 6 increased ruminations and repeated washing (or even bathing), can be 'normalized' at the face of a pandemic response as an exaggerated precautionary measure 7 stocking of masks, soaps, sanitizers, disinfectants that can lead to hoarding and panic shopping. in this context, it is also vital to consider hoarding disorder, which is a part of the broader obsessive compulsive (oc) spectrum in dsm-v. it can be highly comorbid with ocd but also has been considered as a distinct phenotype in many individuals. though, most of the earlier research has focused exclusively on hoarding disorder as a sub-type of ocd, it is now thought to be a distinct disorder with a significant lifetime prevalence of 2-5 percent. also, apart from hoarding items of little use, it has also been shown that need-based hoarding can increase both in ocd and hoarding disorder. the above-mentioned issues apply in a similar way to people who hoard, and their anxiety can increase subsequent to quarantine and nation-wide lockdown in response to the covid-19 threat. this also applies to medications used for symptomatic treatment of flu like analgesics, anti-inflammatory and anti-viral drugs. this can lead to shortage of supplies, agitation in the public and patients with genuine needs being deprived of them. subsequent anxiety might lead to obsessive use of medications like hydroxychloroquine (hcq), which has recently emerged in guidelines for covid-19. however, without adequate supervision and precautions, it can be potentially cardio-toxic and even life-threatening for certain individuals. since covid-19 was declared as a pandemic by who with strict emphasis on washing and disinfection, various media sources have focused on the distress of patients with ocd, increased reporting to the hospitals and first-person accounts of their difficulties. they reported increase of patients with oc symptoms in out-patient departments all across countries like china, united states, united kingdom, italy and india but scientific literature on the statistics are yet to be established (www.time.com) pandemics are not just biological or medical phenomena. they have immense psycho-social implications and affect society at a large. it is well-established that people with pre-existing mental disorders are more prone for relapses, defaulting on medications, stress, stigma, poor self-care and suicidality during pandemics. it also contributes to 'medical mistrust', paranoia, depression that can be compounded by isolation and physical distancing from interpersonal relationships (duan and zhu, 2020) . ocd varies in insight and cases with delusional symptoms might be at a greater risk for decompensation. in previous outbreaks like severe acute respiratory syndrome (sars), middle east respiratory syndrome (mers) and influenza, the exacerbation of ocd has been well-documented especially within 6-12 months after ceasing of the outbreak. whenever the strategies against an infection involve 'repititive behaviors;, it carries the risk of increasing obsessional disorders. it might not be evident in the active phase of the outbreak due to under-detection, disruption of medical services and alternate public health priorities (mak et al., 2009) . especially during the active phase of a pandemic, mental health needs might not be on the publci health forefront leading to worsening of symptoms and late diagnoses. many patients of ocd might have insight but are hesitant to seek help either due to stigma or lack of understanding related to what is 'excess' behaviour in terms of washing and bathing. however, with increasing number of countries affected with passing days of isolation, managing mental disorders has been emerging as a necessity to stabilize quality of lives. the number of ocd patients relapsing in india are increasing at various set-ups, though it is still personal and anecdotal data from most clinicians. we hope to systematically analyze it in the coming days to have a better understanding of the relapses. also, non-essential medical services are suspended at many places as an attempt to contain the outbreak. this can further lead to lack of follow-ups and prescription refills, discontinuation of psychotherapy, and lack of availability of online psychotherapy at many set-ups. though tele-psychiatric practices are increasing, the use and accessibility in many areas are limited. even clinicians continue to have their own challenges and reservations about tele-consultations. especially in developing countries like india, where oc symptoms are also considered to be culture-bound and religion-laden in certain areas, it is difficult to sensitize people and their families to what is 'excessive' washing in a context where everyone is panicking to follow the precautionary instructions. however, awareness is the need of the hour. psychoeducation of the patients and families, debunking misinformation about the pandemic, facilitating tele-consults and online psychotherapy, using the psychiatric social work support to follow-up on severe and treatment resistant patients, ensuring drug compliance are necessary steps to help people who are in need. it is vital to explain to them the context and circumstances of washing and make them realize what is 'out of proportion'. similarly, any unnecessary hoarding needs to be minimized. uncontrolled obsessions and compulsions can lead to dermatological conditions, chronic stress, insomnia and high risk for suicide. more so, when the overall panic and fear of a pandemic is looming large. lack of inhibitory control in ocd can run into a vicious loop thus bringing in a chronic sense of vulnerability to the infection, hence increased thought of contamination and increased washing. both the psychiatrists and allied specialties need to be sensitized to this. we need to be prepared for the likely surge of such cases, especially in the next 3-6 months. primary health-care workers at various sites need to be trained to identify oc complaints and the necessary referrals. the pandemic will eventually die down, but the increased frequency and intensity of this disturbing mental disorder will be an unfortunate aftermath for many months to come. none. supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.psychres.2020.112966. diagnostic and statistical manual of mental disorders (dsm-5®) symptom dimensions in obsessive-compulsive disorder and obsessive beliefs psychological interventions for people affected by the covid-19 epidemic long-term psychiatric morbidities among sars survivors key: cord-262085-y90w53xo authors: neto, modesto leite rolim; de souza, ricardo inácio; quezado, rosa magda martins; mendonça, elayne cristina santos; de araújo, tallys iury; luz, dayse christina rodrigues pereira; de santana, willma josé; sampaio, juliana ribeiro francelino; carvalho, poliana moreira de medeiros; arrais, tereza maria siqueira nascimento; landim, josé marcondes macedo; da silva, claúdio gleideston lima title: when basic supplies are missing, what to do? specific demands of the local street population in times of coronavirus – a concern of social psychiatry date: 2020-04-13 journal: psychiatry res doi: 10.1016/j.psychres.2020.112939 sha: doc_id: 262085 cord_uid: y90w53xo background: homeless experts and some federal housing officials are sounding the alarm that the patchwork of government efforts to address the coronavirus outbreak risks leaving out one group of acutely vulnerable people: the homeless. in terms of isolation, it is too unclear what that looks like if you normally sleep on the streets. in this tough moment, when people should be turned away, not only it feels inhumane, but it is also a big public health risk, because where are they going to go? method: the studies were identified using large-sized newspapers with international circulation results: with more cities suspecting community transmission of the novel coronavirus, people who sleep in shelters or hunker down outside already have a lower life expectancy and often have underlying health conditions that put them at greater risk if they develop covid-19 (global news, 2020). these people face lack of sleep, malnutrition, and “extreme stress levels just to meet their daily needs”, all of which weakens the immune system. along with mental illness or substance abuse disorders, they are “incredibly vulnerable to this virus”. conclusions: health organizations are well aware of the risks involved in mental health. a large population of homeless people experience their pain and psychological distress intermittently. for low-income patients, the various borderline situations related to health/illness involve growing expectations regarding the basic needs. this is a serious concern when linked to the pandemic. severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is infecting people around the world. coronavirus disease will probably be transmitted to people experiencing homelessness. this will become a major problem, especially in north america, where there are sizable populations of people experiencing homelessness in nearly every metropolitan city in the usa and canada. in the usa, more than 500,000 people were reported to be experiencing homelessness on any given night over the past decade (2007) (2008) (2009) (2010) (2011) (2012) (2013) (2014) (2015) (2016) (2017) (2018) (2019) (the council of economic advisers, 2019) . homeless experts and some federal housing officials are sounding the alarm that the patchwork of government efforts to address the coronavirus outbreak risks leaving out one group of acutely vulnerable people: the homeless. housing advocates say they fear an outbreak could occur in large homeless encampments, where thousands of people live on the streets and lack the ability to self-quarantine, receive medical attention or access cleaning facilities (the washington post, 2020). the idea of police arresting homeless people, many with complex health and addiction issues, without proper testing, and placing them in detention centers, just does not sit right (bbc, 2020) . in terms of isolation, it is too unclear what that looks like if you normally sleep on the streets. in this tough moment, when people should be turned away, not only it feels inhumane, but it is also a big public health risk, because where are they going to go? (sky news, 2020) . the plans in each country differ in scope, pace, and ambition and reflect the specific demands of the local homeless population, which has yet to report a case of covid-19. whether these approaches will be effective in the long-term remains unclear. for those living in encampments scattered throughout cities or bedding down in crowded shelters, containment or mitigation might prove elusive (los angeles time, 2020). people experiencing homelessness not only have a set of challenges that make it really hard to do what has been asked -stay home when you are sick, wash your hands frequently, talk to your medical provider if you are feeling ill -, but also their health condition is worse than of many other people. although the coronavirus is affecting people around the world, it is imperative that we have a lens focused on the potential to endanger those living on streets (usa today, 2020) . but what happens when you do not have a home? how do you practice social distancing when, at best, the only barrier between you and your neighbor is a nylon tent wall? that is the question facing the homeless individuals, and one that is vexing lawmakers and public health workers as they try to prevent the spread of covid-19 among a particularly vulnerable segment of the population (fox news, 2020) . with more cities suspecting community transmission of the novel coronavirus, people who sleep in shelters or hunker down outside have a lower life expectancy and often have underlying health conditions that put them at greater risk if they develop covid-19 (global news, 2020) . these people face lack of sleep, malnutrition and "extreme stress levels just to meet their daily needs", all of which weakens the immune system. along with mental illness or substance abuse disorders, they are "incredibly vulnerable to this virus. and the more obvious: they may have trouble accessing hand sanitizers and hand-washing facilities" (abc news, 2020). public health agencies at all levels of government have a role to play in mitigating the coronavirus effects. if public health agencies from local governments to the centers of disease control (cdc) do not have the capacity because of budget cuts or a lack of commitment, local jurisdictions will not have the tools necessary to reach out to those at risk that will be necessary to contain the virus and mitigate its effects on our most vulnerable groups (the conversation, 2020). in the state of washington, the number of schoolchildren on the streets increased dramatically in the past decade, now reaching about 40,000 students. a fifth of them are in seattle and king county. this is worrying and alarming for decision-making in the spaces of social psychiatry. as a whole, the homeless are disproportionately young. in the usa, in general, 22% are aged 60 or older, but among those who stayed in a shelter at some point during 2017, only 5.4% were 62 or older. in san francisco, 10% of the homeless are aged 61 or older. in new york, 7% of sheltered single adults are over 65 years old. los angeles county reports that 6.5% of its street population is aged 62 or older. the relative youth of the homeless is likely a macabre testament to their low life expectancy and poor health (city journal, 2020). spreading information, providing easier access to washing facilities and monitoring health would be a start. however, on a wider scale, this situation seems to shine a light on the ways in which, as a society, we forget about people among us who have nothing. perhaps it is time to reconsider the ethical basis of our communities and our social system. what moral nation can allow its citizens to live without shelter, safety or dignity? (the guardian, 2020). health organizations are well aware of the risks involved in mental health. a large population of homeless people experience their pain and psychological distress intermittently. for low-income patients, the various borderline situations related to health/illness involve growing expectations regarding the basic needs. this is a serious concern when linked to the pandemic. mlrn, dcrpl, wjs, and jmml designed the review, developed the inclusion criteria, screened titles and abstracts, appraised the quality of included papers, and drafted the manuscript. mmm, ris, rmmq, ecsm, tia, pwgf, and jlsm reviewed the study protocol and inclusion criteria and provided substantial input to the manuscript. mlrn, jmml, cgls and tmsna reviewed the study protocol. mmm read and screened articles for inclusion. all authors critically reviewed drafts and approved the final manuscript. the research group: suicidology -universidade federal do ceará (ufc) and brazilian national council for scientific and technological development (cnpq) -institution linked to the brazilian department of science, technology and innovation to encourage research in brazil. the authors declare that they have no competing interests. coronavirus and the homeless: why they're especially at risk, ways to stop a spread 'like wildfire coronavirus: 'safe spaces' needed for homeless to self-isolate another vulnerable population -the homeless present special challenges in the current crisis california moving homeless to hotels, in scramble to prevent coronavirus explosion on the streets coronavirus: homeless canadians need help from governments, advocates say an unexpected side effect of the coronavirus? a new urgency about helping homeless people coronavirus: how do you self-isolate if you are homeless? coronavirus could hit homeless hard, and that could hit everyone hard the state of homelessness in america the guardian, 2020. coronavirus and the risk to the homeless fears mount about impact of coronavirus on homeless why the homeless, 'surviving the best way they can the authors would like to thank the research group: suicidology -universidade federal do ceará (ufc) and brazilian national council for scientific and technological development (cnpq) -institution linked to the brazilian department of science, technology and scientific writing lab, medicine school -universidade federal of cariri (ufca). key: cord-323775-sonsrf5b authors: franchini, linda; ragone, nicola; seghi, federico; barbini, barbara; colombo, cristina title: mental health services for mood disorder outpatients in milan during covid-19 outbreak: the experience of the health care providers at san raffaele hospital date: 2020-07-21 journal: psychiatry res doi: 10.1016/j.psychres.2020.113317 sha: doc_id: 323775 cord_uid: sonsrf5b the spread of covid-19 throughout italy, particularly lombardy, led to adopt quarantine measures, known to exacerbate pre-existing psychiatric conditions. we described a telephone-based surveillance on 101 euthymic mood disorder outpatients in milan by a non-standardized survey to evaluate reactions to lockdown measures and the presence of quarantine stressors. frustration was the most represented quarantine stressor. being jobless was significantly related to the presence of frustration, somatization, increased alertness, psychic anxiety and low mood; younger age to the presence of psychic anxiety, alertness and financial concerns. no recurrences were observed at the time of writing. the rapid spread of the novel severe acute respiratory syndrome coronavirus-2 (sars-cov-2) throughout the italian country resulted in a tragic epidemic that led the italian government to impose emergency measures such as quarantine and social isolation. quarantine is an unpleasant experience for those who undergo it and boredom can occasionally create dramatic effects, sometimes leading to suicide (barbisch et al., 2015) . if domestic lockdown and social isolation have proved to be quite effective as physical containment for infections, it might prove risky from a psychological point of view due to the onset of distressing feelings such as uncertainty, fear, and despair (poletti et al., 2018) . if environmental stressors may have negative consequences on individuals without a psychiatric history, their effect on patients with pre-existing mental disorders may become even more detrimental, eventually resulting in relapses or worsening of their mental condition (hawryluck et al., 2004) . considering that this is the first experience of such a collective social trauma in italy, no analyses have focused on the potentially negative role of quarantine restrictions on mood disorder patients yet. lombardy is the italian region most severely affected by covid-19 and, at the time of writing, the total number of positive cases in milan reached 14,161 (data from civil protection); nationwide restrictions on travels and quarantine have resulted in difficult and impractical attending of regular psychiatric visits. to minimize the risk of infection arising from travels and social interactions, the italian ministry of health indicated that outpatients in clinically stable conditions should be monitored using telemedicine approaches (e.g., phone, smartphone, laptop, or other devices) for the duration of the italian lockdown (started from 9 th march 2020). among these patients, it has been requested to evaluate the following parameters: 1) their physical conditions; 2) their knowledge of the pandemic situation; 3) their adherence and tolerance to quarantine restrictions; 4) occurrence of subclinical syndromes or new episodes of their psychiatric illness, to better understand their needs and concerns. the present report aims at describing the telephone-based mental illness surveillance on mood disorder patients attending the mood disorder outpatient center at san raffaele hospital in milan, with the aid of a non-standardized survey to evaluate reactions to lockdown measures. the subjects affected by major depressive disorder (mdd) or bipolar disorder (bp) who had a scheduled psychiatric visit during the italian lockdown period (9 march-9 april 2020) at our center, were contacted by phone to assess their clinical conditions. the inclusion criteria for our study were being in euthymic conditions according to the clinical judgment of the referring psychiatrist, having previously signed a written informed consent to participate in the ongoing observational study at our hospital approved by the local ethical committee, and verbally agreeing to answer our questionnaire for clinical and research purposes. scheduled patients underwent a telephone-based consultation by their reference psychiatrist concerning their physical (temperature > 37.5, cough, cold, sore throat, dyspnea) and psychiatric conditions. the consultation was integrated with a short, non-standardized instrument created in the emergency of the current pandemic situation. the tool consisted in a questionnaire assessing the presence of items regarding emotional stressors (fear of infection, frustration due to restrictions, adequacy of supplies, adequacy of information, financial concerns), unpleasant experiences during the lockdown (sleep disturbances, mood or anxiety symptoms, increased dosage of anxiolytics and/or hypnotics) (brooks et al., 2020) , and satisfaction with the questionnaire itself. each item was rated as present, absent, or not answered. if present, the severity was rated on a likert scale. answers were reported in the medical record and were collected together with demographic and clinical data of interest (age, sex, duration of euthymia, duration of maintenance treatment, household composition, employment status, close contact with people affected by covid-19, and personal history of covid-19). using the stat-soft statistica 8.0 bivariate correlation analyses have been carried out to evaluate the association between clinical (diagnosis, euthymia and maintenance treatment duration), and demographic variables (age, sex , living alone, employment status) to quarantine stressor in order to identify predictive variables for multiple regression. at the time of writing quarantine has been going on for 37 days. one-hundred and one patients were screened for enrolment, all of which met the inclusion criteria. no missing data were reported. our sample showed a mean age of 61.9±12 yrs, and an average period of euthymia of 30 months, with a mean long-term treatment period of 15.2±13 years. fifteen out of 101 patients (14.8%) experienced covid-19 among their relatives whereas none of them reported to have personally suffered from covid-19. furthermore, 32.6% lived alone and 66.4% were unemployed. table 1 reports clinical and demographic characteristics of the sample, the percentage of each stressor reported and their significant correlations. among our sample, 76% of patients reported frustration due to restrictions, 53.5% fears about infection, 45.5% financial concerns, 44.5% psychic anxiety, 40.6% low mood, 36.6% somatization, 31.6% increased alertness, 29.7% insomnia, 20.8% self-medication with sedatives, 2.9% inadequate supplies. current age and employment status were the variable significantly correlated to quarantine stressors. according to multiple regression analysis, employment status was negatively significantly associated with frustration (beta -0.23), somatization (beta -0.34), alertness (beta -0.36), psychic anxiety (beta-0.20) and low mood (beta -0.21) ; age was negatively significantly associated with psychic anxiety (beta -0.27), financial concerns (beta -0.19) and alertness (beta-0.24). no patient reported symptoms of early mood disorder recurrence. all patients showed appreciation for this type of tele-monitoring. the purpose of our brief report is to describe the telephone-based mental illness surveillance on the quarantine effects in a sample of euthymic mood disorder patients who could not attend their scheduled psychiatric visit due to lockdown measures. the potential negative role of quarantine restriction on mood disorder patients depends on the high susceptibility to lifestyle-mediated disturbances of biological and social rhythms (wang et al., 2019) . in this sense, social isolation, travel restrictions, and home confinement could predispose to an increased risk of affective recurrences. however, we have currently observed no recurrence of illness, supporting the crucial role of a sustained euthymia, reachable with a long-term maintenance treatment in mood disorders (cava et al., 2005) . frustration due to restrictions was the most represented stressor in our sample. this finding is not surprising in a long-lasting clinically stable sample and frustration could represent a normal and understandable response to an atypical and stressful situation such as the covid-19. in fact, loss of usual routine and reduced social and physical contact have been linked to emotional responses, such as frustration, in a non-clinical population (bai y et al., 2004) . on the other hand, presence of frustration could be more harmful in mood disorder patients, considering that may lead to a worsening of the preexisting psychiatric disorders (yao h, et al., 2020 , lima ck et al., 2020 . in our sample, we found significant associations between unemployment and younger age as demographic variables and several quarantine stressors, including frustration. in particular being jobless was significantly related to the presence of frustration, somatization, psychic anxiety and increased alertness, while younger age to the presence of psychic anxiety and financial concerns. lower household income and financial loss are known to be post-quarantine stressors and having a history of psychiatric illness was associated with experiencing anxiety and anger 4-6 months after quarantine (jeong h et al., 2016) . in line with our results, our unemployed and younger patient might be at a higher risk for new recurrences and, therefore, they might benefit from a careful follow-up. we acknowledge that a non-standardized survey should be considered as a major limit, impeding the generalization of our observations. nevertheless, considering the lack of standardized tools and the responsibility to maintain operational psychiatric care during this exceptional gravity situation, our experience can provide a useful contribution. we found very low rates of concerns regarding having inadequate information or supplies, suggesting that the emergency measures taken by the italian authorities were appropriate and adequately released to the population. finally, our experience suggested that telemedicine, although infrequently practiced in the italian psychiatric setting until recently, might be considered as a valid ally against the clinical difficulties encountered during the covid-19 pandemic, supporting patients in their regular psychiatric monitoring. is there a case for quarantine? perspectives from sars to ebola the psychological impact of quarantine and how to reduce it: rapid review of the evidence the experience of quarantine for individuals affects by sars in toronto sars control and psychological effects of quarantine mental health status of people isolated due to middle east respiratory syndrome impact of early and recent stress on white matter microstructure in major depressive disorder circadian rhythm disruption and mental health mar 6). immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china * r= -.1993 p<0.048; ° r= -.2392p<0.017; ** r= -.2042 p<0.043; *** r=-.3452 p<0.0001; § r= .2772 p<0.005 ;**** r=-.2052 p<0.042; °° r= -.2549 p<0.011; °°° r= -.3628 p<0.000; ç r= -2114 p<0.036 key: cord-340535-78bpvtuf authors: elbay, rümeysa yeni; kurtulmuş, ayşe; arpacıoğlu, selim; karadere, emrah title: depression, anxiety, stress levels of physicians and associated factors in covid-19 pandemics date: 2020-05-27 journal: psychiatry res doi: 10.1016/j.psychres.2020.113130 sha: doc_id: 340535 cord_uid: 78bpvtuf aim: to investigate anxiety, stress, and depression levels of physicians during the covid-19 outbreak and explored associated factors in both clinical and general site. methods: an online survey is conducted to asses psychological responses of healthcare workers and related factors during covid-19 outbreak. it is consisted of three subsections covering the following areas: 1) sociodemographic data 2) information on individuals` working condition 3) depression anxiety and stress scale-21 (das-21). results: of all 442 participants, 286 (64.7%) had symptoms of depression, 224 (51.6%) anxiety, and 182 (41.2%) stress. being female, young, and single, having less work experience, working in frontline were associated with higher scores, whereas having a child was associated with lower scores in each subscale. factors found to be associated with higher das-21 total scores in frontline workers were as follows: increased weekly working hours, increased number of covid-19 patients cared for, lower level of support from peers and supervisors, lower logistic support, and lower feelings of competence during covid-19 related tasks. conclusions: our findings highlight the factors which need to be taken into consideration to protect the mental wellbeing of doctors while fighting with a disaster that has major impacts on society worldwide. since december 2019, the world is facing a new contagious disease, covid-19. it is first described in wuhan, china and has spread globally in months. the rapid transmission of the disease and increasing influx of infected cases and associated deaths lead to an enormous panic and anxiety in public. in an early study investigating immediate psychological response during covid-19 epidemic among general population in china, 53.8% of participants rated the psychological impact of the outbreak as moderate or severe (1) . besides psychological aspects of the outbreak on society, healthcare workers (hcws) are subjected to an additional stress due to engaging directly in the treatment of infected patients and increased risk for contagion, fear of transmission to their families, concerns about health of self and loved ones, feeling stigmatized and rejected and working under extreme pressures. on the other side, the increasing number of cases and disease-related deaths, heavy workload for extended period of time and depletion of personnel protection equipment (ppe) cause emotional and physical burnout over time. stress reaction symptoms such as anxiety, depression, somatization and hostility have been reported in about 10% of healthcare workers during and in the aftermath of previous outbreaks (2) . during a recent epidemic sars, a study from taiwan investigated stress reactions among hospital staff and reported 5% suffered from an acute stress disorder, 20% felt stigmatized and 9% reported reluctance to work or had considered resignation (3) . in another study investigating long term psychological effects of sars outbreak on healthcare workers, 23% of staff were found to have moderate or severe depressive symptoms in a 3year follow-up (4) . more recently, during covid-19 pandemic, the prevalence of depression, anxiety and stress-related symptoms were found to be 50.7%, 44.7% and 73.4% respectively, among chinese healthcare workers (5) . however, the evidence is still scarce and little is known about psychological needs of healthcare workers facing with this global disaster. therefore, there is an urgent need for more systematic research to understand the psychological effects of covid-19 outbreak on healthcare workers and related risk and protective factors. based on this perspective, here, we aimed to investigate anxiety, stress and depression levels of physicians during covid-19 outbreak and explored associated factors in both clinical and general site. we hoped, our study would provide a better understanding of psychological needs of our colleagues during this disaster and strengthen preparations in safeguarding their mental wellbeing. a cross-sectional survey was designed to assess psychological responses of healthcare workers and related factors during covid-19 outbreak. we used an online survey to minimize face to face interactions and to facilitate participation of healthcare workers who work extensively during this emergency period. a convenience sample of physicians were contacted to participate in this study. the survey was shared on various social network groups from different specialities. all respondents provided an informed consent at the beginning of the survey with a yes-no question confirming their willingness to participate in the study. data was collected between march 10, 2020 and march 15, 2020. ethical approval for the study was granted by the ethical committee of istanbul medeniyet university with the number 2020/187. sociodemographic data were collected on age, gender, marital status, specialties, number of children, composition of the household, comorbid medical diseases, history of mental disorders, smoking status, alcohol consumption and time spent daily on social media since the outbreak. participants were also asked whether they have ever diagnosed with covid-19 so far. the depression anxiety stress scale (dass) 21 is a self-report tool containing 21 items that assess three constructs: depression, anxiety, and stress (6) . each subscale includes 7 statements. items consist of statements referring to the previous week, respondents are asked to read these statements and rate the frequency of the negative emotions. ratings are made on a series of 4-point likert-type scales from 0 (did not apply to me at all/ never) to 3(applied to me very much/ always). higher scores indicate more severe emotional distress. the validity and reliability studies of the turkish version of the dass-21 were performed by sarıçam et al in 2018 and it was concluded that the scale was a valid and reliable instrument in the assessment of depression, anxiety, and stress levels. (7). data were analysed using spss version 25 (spss inc., chicago, il). in addition to descriptive statistics, we first conducted univariate analyses to explore the associations between psychiatric symptoms and related factors by using either student's t-test and anova test or pearson`s correlation test. then, we conducted multiple linear regression analyses to identify the unique contribution of relevant predictors on the das total and subscale scores, separately. with this purpose, life-time psychiatric history and correlates that showed statistical significance at p-value less than 0.05 in the univariate analyses were included in the regression analysis. as work experience and age were highly correlated variables, we only included age as a covariate in the regression analyses to avoid multicollinearity. all analyses were two-tailed with alpha set at 0.05. 442 people participated in the study. characteristics of the participants are presented in table 1 . the mean age was 36.058.69. there were more females than males in the sample (56.8% vs 43.2%). table 2 presents the working conditions of doctors who work in the frontline during this pandemic. 18.1% (n:80) of the overall sample were smokers. of these, 20 reported an increase, whereas 27 reported a decrease in daily cigarette consumption after the outbreak. 100 people (22.6%) were drinking alcohol in the whole sample. of these, 17 reported an increase, while 34 reported a decrease in alcohol consumption. we asked participants to rate their social media usage during the outbreak. 3.6% reported reduced social media use and 19.5% reported no change. however, social media usage was increased in 48.2% and was extremely increased in 28.7% of the sample. mean das-21 total and subscale scores of the sample were presented in table 1 . of all participants, 286 (64.7%) had symptoms of depression, 224 (51.6%) anxiety and 182 (41.2%) stress. for depression subscale, 17.6% of the sample were reported mild depressive symptoms, 27.4% were reported moderate, 9.5% were reported severe and 10.2% were reported extremely severe depressive symptoms. for anxiety subscale, 16.3% of the sample were considered to have mild anxiety symptoms, 13.1% were considered to have moderate, 10 .6% were considered to have severe and 11.5% were considered to have extremely severe anxiety symptoms. for stress subscale, 10.2% of the sample were reported mild stress symptoms, 15.6% were reported moderate, 10.4% were reported severe and 5.0% were reported extremely severe anxiety symptoms. the findings of univariate analysis for psychiatric symptoms in the overall sample were presented in supplementary table 1 . being female, young and single, having less work experience, working in frontline jobs were associated with higher scores, whereas having a child was associated with lower scores in each subscale. composition of the household was found to be associated with only das total and depression subscale scores. post-hoc analyses revealed that the scores were higher for those who live alone than those living with their spouse and children. having comorbid medical diseases and having diagnosed with covid-19 were not found to be associated with psychiatric symptoms. independently associated with each subscale scores, with the only exception is that age was not found to be associated with das-anxiety scores (p=.195). associations with das-21 total and subscale scores in frontline workers were presented in were independently associated with das-anxiety and stress scores. in addition, higher total number of covid-19 patients cared for was also associated with higher das-stress scores independently (p=.045). the first confirmed case of covid-19 outbreak has been reported in turkey on march 11, 2020 . as in the rest of the world, a rapid transformation and adaptation process started in the healthcare system and immediate steps were taken in our country, as well. we found that being married and having a child were associated with lower das total and subscale scores, whereas being younger and women, having less professional experience and working in the frontline were associated with higher scores in the whole sample. in addition, those living with their spouse and children had lower scale scores than those living alone. regression analysis showed that being a woman, being young, having a history of psychiatric disorders and working in the frontline were independent predictors for worse mental health outcome in almost all subscales. similar to our findings, lai et al indicated that women and frontline workers had a greater risk for developing adverse psychiatric outcomes during covid-19 outbreak in china (5) . in another study investigating the psychological impact of sars outbreak on hospital employees, younger participants and those worked in high risk locations, such as sars wards, were more likely to have high ptsd symptoms (12) . being single was found to increase the odds of having a high level of depressive symptoms in hospital staff, 3 years after the sars outbreak (4). these factors were found to be independently associated with either total scale score or subscale scores after regression analysis. our another finding is the excessive workload is associated with psychological symptoms. for this reason, it should be aimed to ensure appropriate working hours, reasonable rest periods and rotating shifts for workers. logistic support seems to be another to the best of our knowledge, this is the first study in turkey investigating psychological impact of covid-19 outbreak on healthcare workers. however, we recognize several limitations to our investigation. first of all, the study is limited by its cross-sectional nature and lacks longitudinal follow-up. data collection phase of the study was completed within 6 days. given the time sensitivity across this emergency situation, we aimed to explore psychological symptoms of physicians and related factors, so that findings of this study would identify immediate needs of doctors and provide a guidance for implementing relevant intervention policies in the early period to protect their mental wellbeing during this struggle. furthermore, the voluntary nature of the survey might have led to a selection bias and the respondents may not represent well the entire population. lastly, in order to reach as many participants as possible during this emergency time and to minimize face to face interviews, we used a self-report questionnaire to assess psychological symptoms which did not rely upon diagnostic assessment by mental health professionals. in this study, we only investigated depression, anxiety and stress levels of physicians. however, further studies incorporating social support and ptsd assesment in healthcare workers would undoubtly contribute to the litareture. notwithstanding the above limitations, findings of this study provide valuable information on early psychological effects of covid-19 in physicians from different specialties across the country. most importantly, our findings will assist health authorities worldwide in implementing relevant measures to minimize the psychological effects of the largest pandemic of our time on hcws. providing mental wellbeing of healthcare workers is crucial for ensuring the sustainability of healthcare services during our struggle with covid-19. our findings show that women, young and less experienced people and particularly those working in the frontline positions are in the risk group and should be followed closely. our study further indicated that the excessive workload (increased total number of patients cared for and increased weekly working hours, working in both daytime and night-shifts), lower logistic support, lower support from peers and supervisors and lower feelings of occupational competence during covid-19 related tasks cause a more emotional impact in physicians who work in the frontline. 1 50.38 (114.02) support from peers 2 2.35 (0.61) support from supervisors 2 2.14 (0.70) logistic support 3 2.45 (1.07) occupational competence 4 3.18 (1.10) 1 ns varies because of the missing data 2 as measured by a likert scale. possible scores range from 0 to 3, with higher scores indicating better support. 3 as measured by a likert scale. possible scores range from 0 to 5, with higher scores indicating better support. 4 as measured by a likert scale. possible scores range from 0 to 5, with higher scores indicating better competence. immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china long-term psychiatric morbidities among sars survivors. general hospital psychiatry survey of stress reactions among health care workers involved with the sars outbreak depression after exposure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019 the structure of negative emotional states: comparison of the depression anxiety stress scales (dass) with the beck depression and anxiety inventories the psychometric properties of turkish version of depression anxiety stress scale-21 (dass-21) in health control and clinical samples the mental health of hospital workers dealing with severe acute respiratory syndrome the immediate psychological and occupational impact of the 2003 sars outbreak in a teaching hospital stress and psychological distress among sars survivors 1 year after the outbreak psychological effects of the sars outbreak in hong kong on high-risk health care workers the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perception, and altruistic acceptance of risk key: cord-258991-mrs5j2ep authors: huang, yeen; zhao, ning title: generalized anxiety disorder, depressive symptoms and sleep quality during covid-19 outbreak in china: a web-based cross-sectional survey date: 2020-04-12 journal: psychiatry res doi: 10.1016/j.psychres.2020.112954 sha: doc_id: 258991 cord_uid: mrs5j2ep china has been severely affected by coronavirus disease 2019(covid-19) since december, 2019. we aimed to assess the mental health burden of chinese public during the outbreak, and to explore the potential influence factors. using a web-based cross-sectional survey, we collected data from 7,236 self-selected volunteers assessed with demographic information, covid-19 related knowledge, generalized anxiety disorder (gad), depressive symptoms, and sleep quality. the overall prevalence of gad, depressive symptoms, and sleep quality of the public were 35.1%, 20.1%, and 18.2%, respectively. young people reported a significantly higher prevalence of gad and depressive symptoms than older people. compared with other occupational group, healthcare workers were more likely to have poor sleep quality. multivariate logistic regression showed that age (< 35 years) and time spent focusing on the covid-19 (≥ 3 hours per day) were associated with gad, and healthcare workers were at high risk for poor sleep quality. our study identified a major mental health burden of the public during the covid-19 outbreak. young people, people spending too much time thinking about the outbreak, and healthcare workers were at high risk of mental illness. continuous surveillance of the psychological consequences for outbreaks should become routine as part of preparedness efforts worldwide. coronavirus disease 2019 (covid-19, also known as 2019-ncov), a cluster of acute respiratory illness with unknown causes, has occurred in wuhan, hubei province, china since december 2019 (wuhan municipal health commission, 2020; paules et al., 2020; wang et al., 2020) . as of march 25, 2020, a total of 81,846 covid-19 cases in china have been confirmed and 3,287 chinese died from the disease. internationally, sporadic cases exported from wuhan were reported in 193 countries (such as 69,176 cases in italy, 42,058 cases in spain, and 53,588 cases in united states), 5 continents, and 1 international conveyance (712 cases in "diamond princess") (world health organization, 2020a). on january 23, wuhan city closed all access routes to stop the spread of disease. seven days later, the world health organization (who) declared the covid-19 as a public health emergency of international concern (pheic) (world health organization, 2020b). on march 11, the who declared the covid-19 outbreak could be characterized as a "pandemic" as the virus spreads increasingly worldwide. in addition to physical damage, covid-19 also has a serious impact on the mental health of the public. in january 20, china confirmed human-to-human transmission of covid-19 and some medical staff in wuhan had been infected (xinhuanet, 2020) . since then, the public has shown anxiety-related behaviors, causing a significant shortage of medical masks and alcohol across the country. on the night of january 31, due to a news that "shuanghuanglian oral liquid" could suppress covid-19 (people's daily of china, 2020), the public rushed to pharmacies overnight to buy this drug. in addition, many front-line medical staff work more than 16 hours a day on average, causing them to not getting enough sleep. unfortunately, a 37-year-old japanese government worker who was in charge of isolated returnees from wuhan was found to have died from apparent suicide (the japan times, 2020). evidence indicated that covid-19 is a distinct clade from the betacoronaviruses related to human severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers) . several studies showed that mental health problems could occur in both healthcare workers and sars survivors during the sars epidemic (lee et al., 2007; lu et al., 2006; mcalonan et al., 2007) . post-traumatic stress disorder (ptsd) and depressive disorders were the most prevalent long-term psychological condition (mak et al., 2009) . similar results have been reported in the previous study of mers (lee et al., 2018) . based on the above research evidence, we have reason to speculate that the psychological condition of the public may also be affected during covid-19 outbreak. therefore, using a web-based cross-sectional study, we aimed to assess the mental health burden of chinese public during covid-19 outbreak, and to explore the potential influence factors. we hope that our study findings will provide data support for the targeted interventions on psychological health in chinese public during the outbreak. to prevent the spread of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) through droplets or contact, we used a web-based cross-sectional survey based on the national internet survey on emotional and mental health (nisemh), an ongoing, online health-related behavior survey of chinese population, to collected data. this web-based survey of the covid-19 was sent on the internet through the wechat public platform and the mainstream media. all chinese people using wechat or other social tools may see this survey, and answered the questionnaire by scanning the quick response code (qr code) of the questionnaire address or clicking the relevant link. to encourage the recruitment of potential participants, all participants in the survey can receive a report on their mental health after completing the evaluation. this web-based questionnaire was completely voluntary and non-commercial. participants answered the questionnaires anonymously on the internet from february 3 to, 2020 to february 17, 2020. all subjects reported their demographic data, covid-19 related information, and completed three standardized questionnaires which assessed their generalized anxiety disorder (gad), depressive symptoms, and sleep quality. in order to ensure the quality of survey, we set the response range of some items (e.g., the age range was limited to 6-80 years old, some items needed to be answered in reverse) and encouraged participants to answer carefully through questionnaire explanations. in addition, questionnaires that were completed <1 minute or >60 minutes would be excluded from analysis. finally, a total of 7,236 participants who completed the questionnaires (response rate of 85.3%) were included in the analysis. this study was conducted in accordance with the declaration of helsinki, and was approved by the ethics committee of huazhong university of science and technology union shenzhen hospital. electronic informed consent was obtained from each participant prior to starting the investigation. participant could withdraw from the survey at any moment without providing any justification. demographic variables included gender (male or female), age, and occupation. occupation included the following four types: (1) healthcare workers, which included doctors, nurses, and health-related administrators; (2) enterprise or institution workers, which consisted of enterprise employees, national/provincial/municipal institution workers, and other relevant staff; (3) teachers or students, which included teachers or students from universities, middle schools, or elementary schools; and (4) others, which consisted of freelancers, retirees, social workers, and other relevant staff. e. there are already targeted drugs that could cure the disease; f. taking "shuanghuanglian oral liquid" could prevent infection of this disease. of the above six questions, one point was given for each correct answer, and no points were given for each incorrect or uncertain answer. participants with scores ≥5 points, equal to 4 points, and ≤3 points were considered to quite understand, generally understand, and do not understand. we used chinese version of gad-7 (generalized anxiety disorder-7) scale to assess subject's anxiety symptoms. the gad-7 has been previously used in chinese populations, and found to have good reliability (cronbach's alpha=0.90) (tong et al., 2016; wang et al., 2018) . seven items assessed the frequency of anxiety symptoms over the past two weeks on a 4-point liker-scale ranging from 0 (never) to 3 (nearly every day). the total score of gad-7 ranged from 0 to 21, with increasing scores indicating more severe functional impairments as a result of anxiety (spitzer et al., 2006) . for the purpose of this study, we defined a gad-total score of 9 points or greater as the presence of anxiety symptoms (wang et al., 2018) . the center for epidemiology scale for depression (ces-d) in chinese version was used to identify whether participants had depressive symptoms (zhang et al., 2010) , and the chinese version of this scale has been validated and extensively utilized in chinese population (zhang et al., 2010; zhang and li, 2011) . twenty items assessed the frequency of depressive symptoms over the past two weeks on a 4-point liker-scale ranging from 0 (rarely or none of the time) to 3 (most or all of the time). the score range of the ces-d was 0-60 points, and higher scores indicated more severe depressive symptomatology (radloff, 1977) . in our study, ces-d scores greater than 28 points indicated depressive symptoms. the chinese version of the psqi (pittsburgh sleep quality index) scale was used to assess the subject's sleep quality over the past two week (liu et al., 1996) . the psqi scale contains seven components (subjective sleep quality, sleep duration, sleep latency, habitual sleep efficiency, use of sleep medications, sleep disturbance, and daytime dysfunction), and the score for each component rangs from 0 to 3 points. the global psqi score ranges from 0 to 21, with higher scores indicating more severe sleep disorder (buysse et al., 1989) . the chinese version of psqi has been demonstrated to be reliable and valid in chinese population (liu et al., 1996) , and a global psqi score greater than 7 points indicates poor sleep quality. first, descriptive analyses were conducted to describe the demographic characteristics and covid-19 related knowledge in chinese population. second, the prevalence of gad, depressive symptoms, and sleep quality stratified by gender, age, and occupation were reported, and chi-square test (χ 2 ) was used to compare the differences between groups. third, univariate and multivariate logistic regression models were performed to explore potential influence factors for gad, depressive symptoms, and sleep quality during covid-19 outbreak. odds ratio (or), adjusted odds ratio (aor), and 95% confidence interval (95% ci) were obtained from logistic regression models. all data were analyzed using statistical package for social sciences (spss) version 24.0. p-values of less than 0.05 were considered statistically significant (2-sided tests). the characteristics of participants were shown in table 1 . of the 7,236 sample analyzed, 3,284 (45.4%) were males and 3,952 (54.6%) were females, and the mean (standard deviation) age of the participants was 35.3±5.6 years. among these samples, 2,250 (31.1%) of participants were healthcare workers, 3,155 (43.6%) of participants spent 3 hours or more a day focusing on the covid-19 outbreak, and 5,702 (78.8%) of participants quite understand knowledge of the covid-19. the prevalence of gad, depressive symptoms, and sleep quality stratified by gender, age, and occupation were shown in table 2, table 3, and table 4 , respectively. the overall prevalence of gad, depressive symptoms, and sleep quality were 35.1%, 20.1%, and 18.2%, respectively. there was no statistically significant difference in the prevalence of gad, depressive symptoms, and sleep quality by gender (p>0.05, as shown in table 2 ). the prevalence of gad and depressive symptoms was significantly higher in participants younger than 35 years than in participants aged 35 years or older (p<0.001, as shown in table 3 ). compared with other occupational groups, healthcare workers (23.6%) reported the highest rate of poor sleep quality (p<0.001, as shown in table 4 ). the associations of potential influence factors with gad, depressive symptoms, and sleep quality during covid-19 outbreak were presented in in the multivariate logistic regression models, the above associations weakened but there were still statistical difference. participants under 35 years were more likely to have gad than those 35 years and older (aor=1.65, 95% ci: 1.49-2.02). besides, participants who were concerned about the covid-19 outbreak for 3 hours or more were more likely to develop gad than those less than 1 or 2 hours (aor=1.83, 95% ci: 1.53-2.19). similarly, participants under 35 were associated with higher risk for depressive symptoms than those 35 years and older (aor=1.77, 95% ci: 1.58-2.07). compared with other occupation participants, healthcare workers were more likely to report poor sleep quality (aor=1.32, 95% ci: 1.18-1.88). our web-based study shows a high prevalence of gad and poor sleep quality in the chinese public during covid-19 outbreak. anxiety symptoms were more likely to occur in people younger than 35 years and those who spent too much time focusing on the outbreak. compared with other professions, healthcare workers were associated with higher risk for poor sleep quality. our findings provided data support for accurately understanding the source of public's panic during covid-19 outbreak. the data in this study suggested that public's levels of anxiety-related symptoms increased when a major infectious disease occurred. similar to the psychological burden caused by sars (su et al., 2007) , we found that one in three participants showed anxiety disorders, and this mood was not different between male and female during covid-19 outbreak, which was different from previous research that women were more likely to have anxiety than men (guo et al., 2016; gao et al., 2020) . in addition, nearly one in five participants had depressive symptoms and sleep problems, indicating that the uncertainty of the epidemic progression would cause greater psychological pressure on the public. the possible reason for these mental problems may be related to the "hypochondriac concerns" (worry about being infected) (furer et al., 1997) and feared that the epidemic was hard to control. after multivariate logistic regression analyses, we found that age and time spent focusing on covid-19 may be potential risk factors for the psychological problems of the public. younger participants (< 35 years) were more likely to develop anxiety and depressive symptoms during covid-19 outbreak than older participants (≥ 35 years). our results were similar to those of a previous study in taiwan during sars outbreak (su et al., 2007) . in addition, we assessed the average time participants spent focusing on the covid-19 outbreak each day, and found that people who spent too much time thinking about the outbreak (≥ 3 hours) were more likely to develop anxiety symptoms. the manifestation of this panic mood may be related to the body's normal protective response to the stress caused by the epidemic (maunder et al., since january 20, 2020, zhong nanshan (the renowned chinese respiratory expert who discovered the sars virus) confirmed that there must be human-to-human transmission of covid-19 (xinhuanet, 2020), more than 40,000 medical staff have given up the spring festival holiday and voluntarily applied to fight against the outbreak in hubei province (national health commission of the people's republic of china, 2020). meanwhile, most healthcare workers in china have returned to work to cope with the further development of the disease. our findings showed that nearly one in four healthcare workers had sleep problems, which was significantly higher than other occupational groups. one possible reason is that the working time and labour intensity of healthcare workers will increase in the face of severe epidemic (such as sars and mers), causing them not to have enough time to rest, and to be prone to chronic stress and psychological distress (lu et al., 2006; lee et al., 2018; mcalonan et al., 2007) . in severe cases, a post-traumatic stress disorder (ptsd) symptoms may even occur, which is highly correlated with poor sleep (kobayashi et al., 2007) . fortunately, the chinese government has taken many strong national measures in time to avoid further spread of the covid-19 outbreak, including requiring uninfected people to isolate themselves at home, prohibiting all gathering activities, and forcing everyone to wear medical masks to enter public places. however, there is still lack of relevant research on the targeted intervention of the public's psychological problems during the covid-19 outbreak. we filled this research gap by analyzing the prevalence of mental health burden in chinese public stratified by demographic characteristics and exploring related influential factors. several appropriate interventions are recommended as follows: first, psychological interventions should be directed to vulnerable populations which include the suspected and diagnosed patients, young people, and healthcare workers, especially physicians and nurses working directly with patients or quarantined people. second, try to control and limited the time of receiving covid-19 related information within two hours a day, focus only on the necessary information (such as facts and data) and avoid receiving too many harmful rumors (grein et al., 2000) . third, maintain a normal rhythm of work and rest as much as possible, exercise regularly to promote sleep quality, and do not pay too much attention to outbreak information before going to sleep. this study has several limitations. first, since the data and relevant analyses presented here were derived from a cross-sectional design, it is difficult to make causal inferences. second, the study was limited to covid-19 outbreak, and we used a web-based survey method to avoid possible infections, causing the sampling of our study was voluntary and conducted by online system. therefore, the possibility of selection bias should be considered. third, due to the sudden occurrence of the disaster, we were unable to assess an individual's psychological conditions before the outbreak. in conclusion, we identified a major mental health burden of the chinese public during covid-19 outbreak, and young people, people spending too much time thinking about the outbreak, and healthcare workers were at a high risk of displaying psychological issues. previously, when sars occurred in china, the awareness regarding public's mental health related to the epidemic was low, and no targeted psychological guidelines was available to the public, which was in need during the pandemic period. therefore, ongoing surveillance and monitoring of the poor sleep quality was defined as individuals who scored > 7 points. validation of the generalized anxiety disorder-7 (gad-7) among chinese people with epilepsy clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china world health organization, 2020b. current novel coronavirus (2019-ncov) outbreak. accessed reliability and validity of generalized anxiety scale-7 in inpatients in chinese general hospital report of novel coronavirus-infected pneumonia in china the latest: china confirms human-to-human transmission of 2019-ncov, infections among medical staff reliability and validity of the simplified version of the center for epidemiology scale for depression in the national adult population establishing a national urban norm for the center for epidemiology scale for depression a novel coronavirus from patients with pneumonia in china the authors would like to thank all the participants in our study. in addition, we express our heartfelt respect to all healthcare workers who are fighting the epidemic on the front line. finally, we thank ms. qiaohong chen for providing professional language help. key: cord-302117-u7egknq6 authors: zhang, stephen x.; wang, yifei; rauch, andreas; wei, feng title: unprecedented disruption of lives and work: health, distress and life satisfaction of working adults in china one month into the covid-19 outbreak date: 2020-04-04 journal: psychiatry res doi: 10.1016/j.psychres.2020.112958 sha: doc_id: 302117 cord_uid: u7egknq6 we assess the health and wellbeing of normal adults living and working after one month of confinement to contain the covid-19 outbreak in china. on feb 20–21, 2020, we surveyed 369 adults in 64 cities in china that varied in their rates of confirmed coronavirus cases on their health conditions, distress and life satisfaction. 27% of the participants worked at the office, 38% resorted to working from home, and 25% stopped working due to the outbreak. those who stopped working reported worse mental and physical health conditions as well as distress. the severity of covid-19 in an individual's home city predicts their life satisfaction, and this relationship is contingent upon individuals’ existing chronic health issues and their hours of exercise. our evidence supports the need to pay attention to the health of people who were not infected by the virus, especially for people who stopped working during the outbreak. our results highlight that physically active people might be more susceptible to wellbeing issues during the lockdown. policymakers who are considering introducing restrictive measures to contain covid-19 may benefit from understanding such health and wellbeing implications. since the escalation of covid-19 to a public health emergency in china on jan 21, 2020, over a billion people across china have faced restrictions due to varying degrees of confinement such as banning public transport, restricting movement, and imposing a 14-day quarantine after travel wang et al., 2020) . one month into the outbreak, many people were still not working or exercising as usual, which may have associated implications on health and wellbeing. yet, the implications of the unusually prolonged state of not working and exercising on individuals' health and wellbeing remain unknown. it is important to understand not only the implications of the restrictions on covid-19 disease prevalence rates but also the implications of such unprecedented disruptions on the health and wellbeing of the community (brooks et al., 2020) . from a policy perspective, understanding the health and wellbeing of people under the varying degrees of lockdown in china has implications for countries that are just starting to fight coronavirus, as such restrictions started in korea, italy, parts of the us, etc. in march (moodie davitt report, 2020) . to control the covid-19 outbreak, china has enacted restrictive measures "unprecedented in public health history" as stated by who (reuters, 2020) . on january 23, 2020, china locked down wuhan, a metropolitan area of 12 million people (abc news, 2020) . the lockdown in wuhan soon triggered similar measures in all 15 other cities in hubei province with a total of 57 million people. other prefectures (the administrative areas of a city) in china subsequently implemented varying levels of restrictive measures. for instance, the prefecture of wenzhou in zhejiang province restricted its citizens in such a way that only one person per household could leave home once every two days. such restrictive measures in china seemed to be effective in containing the spread of covid-19 by mid-february and were applauded by who (the washington post, 2020). however, those measures have disrupted people's jobs and lives immensely and hence may have important implications for their health and wellbeing (lima et al., 2020) . for example, evidence from the sars crisis indicated that reduced mobility affected the wellbeing of quarantined residents in a complex https://doi.org/10.1016/j.psychres.2020.112958 received 25 march 2020; accepted 27 march 2020 manner. cao et al., 2020 found students in their medical college in china experienced more stress and anxiety during the outbreak. a paper in bmj designed a covid-19 peritraumatic distress index to assess the distress level of people during covid-19 outbreak (qiu et al., 2020) . these papers are critical because across the world people who did not carry the virus epidemiologically but had their work and life disrupted to varying degrees (duan and zhu, 2020; xiang et al., 2020; bao et al., 2020) . in this article, we aim to use existing scales of health, distress and life satisfaction to identify the health and wellbeing of people one month into the disruption caused by confinement measures to contain covid-19 outbreak by their work status, chronic health conditions, and exercising hours. understanding the health and wellbeing implications of the measures introduced to reduce the covid-19 infection allows better-informed decisions. as many parts of the world are starting to consider measures to contain covid-19, with south korea and italy having introduced lockdowns in early march 2020 , we may benefit from understanding the health and wellbeing implications of the measures implemented early on in china. we conducted a cross-sectional survey one month into the covid-19 outbreak on february 20-21, 2020, about one month into the covid-19 emergency in china. all the participants were adults not infected by the virus epidemiologically but they lived in locations that were affected by covid-19 to varying degrees. to cover people in areas of varying severity of covid-19, we surveyed adults from 64 prefectures across china. the 64 prefectures were chosen to cover a wide spectrum of regions based on the severity of covid-19 and should not be taken as a representative national sample. all respondents agreed to participate in the study, which was approved by the ethics committee at tongji university (#20200211). we reached 529 adults, and 369 of them answered the survey, with a response rate of 69.8%. the participants were not involved in the design, or conduct, or reporting, or dissemination plans of this research. we assessed individual health by the short form-12 (sf12), a standard scale on mental and physical health function (ware et al., 1996) . the scale had been translated into chinese and validated in china (zhang et al., 2011) . sf12 contains 12 items and 8 dimensions: physical functioning (2 items), role physical (2 items), bodily pain (1 item), general health (1 item), vitality (1 item), social functioning (1 item), role emotional (2 items) and mental health (2 items). the eight dimensions form two composite scores of physical and mental composite scale (pcs and mcs), with a possible score ranging from 0 to 100 (ware et al., 2002) . as a formative score, a higher sf12 score indicates a better health condition. we measured distress by the six-item kessler psychological distress scale (k6) with a cronbach's alpha of 0.79 (kessler et al., 2002) . we measured life satisfaction with the satisfaction with life scale (swls) (diener et al., 1985) , which consists of five items with a cronbach's alpha of 0.72. the adults also provided their socio-demographic characteristics, such as gender, age, education, and their location (prefecture). using their locations, we searched for the number of confirmed covid-19 cases in their prefectures on february 20 as well as the total population to calculate the number of confirmed cases per 10,000 people as an indicator of the severity of covid-19 at their location. the number of cases per 10,000 people (i.e. infected rate) varied from 42.45 (wuhan) to 0.01 on february 21 (national health commission of the prc, 2020). because covid-19 is more dangerous for people with comorbidity (gates, 2020) , it is likely that people who have ongoing medical issues would suffer more during the outbreak and therefore we asked whether the participants had any chronic disease. on the contrary, people who lead a healthy lifestyle and exercise often would be expected to fare better during the outbreak. hence, we also asked the participants to indicate 'how many hours did you exercise per day during the past week'. the restrictive measures of covid-19 also caused major disruption to people's work. by the time of our survey on february 20, the growth rate of covid-19 cases in china had fallen to single percentages per day. some people still stopped work, while some had returned to work in offices, and others were working at home. all individuals reported their work status. we report the descriptive statistics of the study variables and the regression models to examine the relationships. the first and second author did the analyses on unweighted data with stata 16.0, and statistical significance was assessed by p < 0.05. table 1 presents the descriptive characteristics of the participants. from january 21 to february 20, in the one month of the restrictive measures, 124 (33.6%) of the participants had not left home at all, 51 (13.8%) had left their home only once, and 81 (22.0%) had left their home more than five times. at the time of the survey, 99 (26.8%) were going to work at their office; 93 (25.2%) had stopped working; and 139 (37.7%) resorted to working from home; 32 (8.7%) participants had not been working before the outbreak started; and 6 (1.6%) reported losing their work during the covid-19 outbreak. in terms of exercise, 51 (13.8%) people had not exercised at all during the past week; 226 (61.2%) exercised but for less than 1 h per day; 63 (17.1%) exercised 1-2.5 h per day; and 29 (7.9%) exercised more than 2.5 h per day. of the participants, 45 (12.2%) had chronic diseases. based on the scoring algorithm of sf12, 16 the participants scored 48.74 (sd 9.30) in mental health (mcs) and 49.55 (sd 7.00) in physical health (pcs). the mean values of distress and life satisfaction of the participants were 1.41 (sd 0.46) and 3.22 (sd 0.64) respectively. 3.1. people who worked in the office, worked at home, or had stopped working differed in health (sf12) and distress (k6) table 2 shows the results of regressing sf12 on the job status of the participants one month into the covid-19 outbreak. compared with people who stopped working during the outbreak, people who worked at their office had better mental health (β = 3.46, p = 0.01, 95% ci 0.79-6.14) and physical health (β = 2.19, p = 0.01, 95% ci 0.20-4.18). moreover, people who worked at home also had better mental health than those who stopped working (β = 2.60, p = 0.03, 95% ci 0.05-5.16). we did further analysis on the eight specific dimensions of sf12. compared with people who returned to work at their office, those who stopped working reported lower general health (β = −0.28, p = 0.03, 95% ci −0.55 to −0.03), mental health (β = −0.38, p = 0.002, 95% ci −0.63 to −0.14), and increased limitations for physical issues (β = −0.16, p = 0.009, 95% ci −0.28 to −0.04) and emotional issues (β = −0.13, p = 0.03, 95% ci −0.26 to −0.01). there were fewer differences between people who worked at home and worked at offices, except those who worked at home reported more limitations for physical issues than those who worked at offices (β = −0.13, p = 0.02, 95% ci −0.24 to −0.02). there were also certain dimensions of sf12 that did not vary much by job status. for instance, people who stopped working and those who worked at their offices did not differ in bodily pain (β = 0.16, p = 0.16, 95% ci −0.06 to 0.39), physical function (β = 0.10, p = 0.14, 95% ci −0.03 to 0.24), and social function (β = 0.22, p = 0.26, 95% ci −0.16 to 0.59). those who stopped working and those who worked at home respectively also did not differ in the same dimensions of bodily pain (β = 0.15, p = 0.19, 95% ci −0.07 to 0.36), physical function (β = 0.00, p = 0.96, 95% ci −0.13 to 0.13), and social function (β = 0.19, p = 0.29, 95% ci −0.17 to 0.55). similar findings emerged from the regression results on distress (k6) and life satisfaction (table 3) . people who worked at their office suffered less distress than people who stopped working (β = −0.13, p = 0.05, 95% ci −0.25 to 0.00). also, people who worked at their office reported higher life satisfaction than those who stopped working (β = 0.23, p = 0.02, 95% ci 0.03-0.43). next, we analysed how the severity of covid-19 in individual locations predicts individuals' life satisfaction. table 4 shows that the relationship between the severity of covid-19 and individual life satisfaction depends on individuals' existing health and exercise status. the severity of covid-19 had a negative relationship with the life satisfaction only for people with chronic medical issues (β = −2.11, p = 0.04, 95% ci −4.09 to −0.13) but not for people without chronic medical issues (β = −0.01, p = 0.51, 95% ci −0.02 to 0.01). we plot the effect of the severity of covid-19 on life satisfaction by whether the individuals had chronic medical issues in fig. 1 . the results also indicate that the relationship between the severity of covid-19 in a location and life satisfaction depends on individuals' level of exercise, but in a direction opposite to our expectation. while table 4 the severity of covid-19 in a location interacts with individuals' chronic health condition and exercise time to predict their life satisfaction. we expected people who exercised more during the outbreak had a healthy lifestyle and would be less influenced, for people who exercised more than 2.5 h per day during the outbreak, the relationship between the severity of covid-19 in their location and life satisfaction was significantly negative (e.g. for people who exercised 3 h per day: β = −0.02, p = 0.04, 95% ci −0.04 to 0.00). the relationship is not significant for people who exercised between 1 and 2.5 h a day during the outbreak. surprisingly, for people who exercised 0.5 h or less per day during the outbreak, their life satisfaction was significantly positively associated with more affected locations (e.g. for people who did not exercise: β = 0.04, p = 0.02, 95% ci 0.01-0.08). we plot the effect of the severity of covid-19 in the location on life satisfaction by the exercise hours of individuals in fig. 2 . although the hardline restrictive measures in china showed success in containing covid-19 after a month, there is little research on the extent to which the disruptions affected people in the community. our findings show that adults who were not working reported worse health, as captured by sf12 in certain dimensions as well as distress (k6). the insignificant differences in the dimensions of sf12 in bodily pain, physical function and social function are expected, because people who were not infected by the virus directly would not differ much in those dimensions. the results on life satisfaction are more nuanced. overall, the severity of covid-19 in a prefecture did negatively predict people's life satisfaction in that prefecture, with this relationship depending on individuals' existing medical conditions and exercise levels. for individuals who exercised a lot during the outbreak (>2.5 h per day), life satisfaction was significantly negatively associated with more affected locations; on the contrary, for individuals who exercised half an hour a day or less, life satisfaction was significantly positively associated with more affected locations. maybe these people could better justify or rationalize their inactive lifestyles in more severely affected cities. the finding that those who exercised a lot (>2.5 h per day) were less satisfied in more affected cities suggests we may need to pay attention to more physically active individuals, who might be more frustrated by the restrictions due to the outbreak. the study has certain limitations. first, this study relied on an observational survey. because the measures of the dependent variables of sf12, distress and life satisfaction used likert scales, we tried to use predictors that were non-likert scales, such as job status and severity of covid-19 calculated based on archival data using the reported locations. second, our sample is not a national representative sample. our focus was to examine the differential effects on adults depending on the level of disruption, as captured by their job status, existing chronic issues, and exercise levels to identify who in the community of non-covid-19 cases might need the most help for policymakers and potential caregivers. third, even though we had data from people who had not been working even before the outbreak started (8.7%) and people who went out of work during the outbreak (1.6%), the sample size of those two groups was small and we are cautious not to report them in the findings. nevertheless, people with these two job statuses could be important targets for future studies. we provide preliminary evidence on the health conditions of adults in covid-19 affected regions. the identification of who might be more affected by covid-19, not epidemiologically but simply by working and living in affected regions, carries important implications. such identification can help to prioritize those who might need more help, and psychologists, mental health professionals and social workers can provide services to start addressing at least the mental health issues, even during the lockdown. affected regions are growing globally by the day, and covid-19 is no longer confined to china (cohen and . to contain covid-19 transimission , policymakers in other countries are considering implementing restrictive measures . we present this early evidence of disruptions one month into the outbreak to provide evidence on the health of the general community living and working under restrictive measures. stephen x. zhang: conceptualization, methodology, formal analysis, writing -original draft, writing -review & editing, supervision. yifei wang: validation, visualization, writing -original draft. andreas rauch: writing -original draft, writing 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data collection was funded by the chinese national funding of social sciences (grant number: 1509093). supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.psychres.2020.112958. key: cord-296207-77dbdxjt authors: lenno, jack c. title: unintentional injury fatalities in the context of rising u.s. suicide rates: a five-year review of the web-based injury statistics query and reporting system date: 2020-05-11 journal: psychiatry res doi: 10.1016/j.psychres.2020.113066 sha: doc_id: 296207 cord_uid: 77dbdxjt this archival study focuses specifically on suicide fatalities in relation to unintentional and undetermined injury fatalities in an effort to determine whether or not these rates are rising consistently. this question may serve to inform whether or not suicides are being accurately reported and documented. data from all 50 states from the years 2012-2016 were obtained from the web-based injury statistics query and reporting system (wisqars) developed by the centers for disease control and prevention. a total of 213,726 suicide fatalities, 702,176 unintentional injury fatalities, and 24,533 undetermined injury fatalities comprised the dataset. injury fatality rates depicted annual increases in both suicide and unintentional injury fatalities but variability in undetermined injury fatalities. bivariate analyses discovered a statistically significant association between annual suicide fatality rates and unintentional (nonsuicidal) injury fatality rates. it would be suspected, ceteris paribus, that calculated rate changes over these years would follow suit. however, this was not observed. given the trends and increasing stigma surrounding suicide, it is worth considering the degree to which suicides may be underreported or -documented and the epidemiological and translational ramifications of these trends as they pertain to future suicide research. suicide is often broadly defined as intentional self-harm intended to and resulting in death. the united states (u.s.) alone has observed consistent annual increases in suicide rates, with the current rate being the highest it has been in 50 years (drapeau & mcintosh, 2020) . further, the rate of suicide attempts has increased by 250% in global conflict zones over the past 18 years (shoib & kim, 2019) . however, there are clear issues with this broad definition due to suicide attempts (sas) during which the individual's life does not end, which may be due to nonlethal means or rapid medical intervention. intentionality is a key philosophical and psychological component but cannot always be determined by outside investigators or even consciously by the suicidal individual (münster & broz, 2016) . impulsivity is also a heterogeneous concept that harbors inaccurate implications as it relates to suicide (cole et al. 2019 ). suicidal thoughts and behaviors (stbs) come in many forms, including not only sas but nonsuicidal self-injury (nssi) and other risk-taking behaviors such as drug and alcohol use (ammerman et al. 2016) , reckless driving (start et al. 2018) , and hostile behavior (mckinney et al. 2017) . these behaviors are provoked by psychosocial stressors and associated with suicide deaths (athey et al., 2018) . suicide rates are known to peak in the summer months and drop in winter months (kim et al., 2004; sawa et al., 2016) . interestingly, the effects of sunshine are thought to implicate the serotonergic system, though one study found that the relationship between suicide and sunshine became non-significant when controlling for season. this relationship became significant among individuals undergoing selective serotonin reuptake inhibitor treatment (makris et al., 2016) . college students experience more suicidal ideation in the summer and attempts in late spring and early summer. perceived belongingness was a factor that seemed to contribute to this seasonal suicide & unintentional injury fatalities 5 association (van orden et al., 2008) . in terms of fatal injuries, approximately one-third of motor vehicle-related deaths in iran occur in the summer months (khorshidi et al., 2016) . trafficrelated traumatic brain injuries in the slovak republic have also been noted to be highest in the summer months (taylor et al., 2020) . the u.s. follows this trend, such that motor vehicle accidents peak in the summer rather than the winter (rau et al., 2018) . in fact, one study found that warm temperatures that extend beyond the norm are associated with increased injury fatalities (parks et al., 2020) , such that summer appears to be a consistently risky time of year for both suicide deaths and injury fatalities. noteworthy are the complex, bidirectional associations between biological and psychological components on suicide risk. changes in these risk factors both impact and are impacted by the external environment, which is often comprised of recursive events that have variable impacts across individuals. in fact, one study found that those who experience the death of loved ones by suicide experience long-term emotional turmoil, presenting as its own risk factor for their own suicides (pompili et al., 2013) . this is important because it is estimated that 135 people are exposed to each suicide death, resulting in roughly 6.9 million exposed survivors each year (cerel et al., 2018) . from a neurobiological perspective, serotonergic system alterations is one of the most common findings in suicide research, including expression of 5hydroxytryptamine (5-ht) receptor subtypes, downregulation of brain-derived neurotrophic factor (bdnf), and epigenetic alterations such as histone and deoxyribonucleic acid (dna) methylation modifications (gould et al., 2017) . these findings suggest that depressed individuals, suicide attempters, and those who die by suicide may exhibit distinct biomarkers. these serotonergic disturbances are thought to be met with compensatory mechanisms involving thyroid and hormones and prolactin (pompili et al., 2012) . for example, free triiodothyronine (ft3) tests, which assess thyroid function, have been found to distinguish between suicide attempters and non-attempters, such that attempters are 2.27 times less likely to have higher ft3 values than non-attempters (pompili et al., 2012) . further, sex, suicidal status, and their interaction were found to have statistically significant effects on prolactin levels independent of ft3 values, suggesting that biological mechanisms extend beyond 5-ht and bdnf. thus, vast extant literature suggests that a complex interplay of recursive biological mechanisms may indicate suicide risk and eventually predict this behavior in those at risk. there are injurious causes of death noted on wisqars such as poisoning (general), suffocation, and drowning that may be misrepresented due to an inability for a medical examiner to determine the decedents' intentions. further, a study of veterans found that approximately one-third of suicide attempters had no mental health diagnoses (ursano et al. 2018 ). approximately 50% of older individuals who die by suicide are believed to have had physical health problems that precipitated the act, resulting in controversy in cause of death if suicide is unclear or ambiguous (choi et al. 2019). overdoses may be included in poisonings and the other causes of death are also known to be ranked in the top five of suicide methods. however, the most common cause of reported suicide deaths is firearms, which is arguably easier to determine intentionor the individual who used the firearmfor both law enforcement investigators and medical examiners. ward and colleagues (2011) discovered significant differences between the circumstances reported in medical examiner and police reports, including alcohol or drug dependence, financial considerations, and recent familial deaths, suggesting that this lack of continuity and integration serves to reduce overall reporting statistics that could improve prevention tactics. other evidence supports that death certificates are inconsistent with centers for disease control and prevention (cdc) guidelines between 20% and 85% of the time across u.s. hospitals (lloyd et al., 2017) , which is no different than the suicide classification difficulties published by the cdc over three decades ago (cdc, 1988) . other studies, however, have found concordance between classifications and vital statistics (gatov et al., 2018) . the national violent death reporting system (nvdrs) is one such effort utilized to compile data on specific causes of death with the use of such variables as whether or not a suicide note was left by the decedent (karch et al., 2009) [wisqars], 2018). furthermore, it is a warranted speculation that suicide rates are likely higher than those reported due to a multitude of factors. this article focuses specifically on suicide fatalities as they relate to unintentional and undetermined injury fatalities deemed nonsuicidal in an effort to determine whether or not these rates are rising consistently with those attributed to suicide. it is hypothesized that, if associations between suicide and undetermined injury fatalities exist and suicides are being reported appropriately, these rates will also be associated. however, with a rise in concern related to suicide and substantial growth in extant literature on the subject, this may not be the case. data for the current retrospective study were obtained from the cdc web-based injury statistics query and reporting system (wisqars, 2018) for years 2012-2016. data from all 50 states were included in the data set. statistics pertaining specifically to suicide deaths were corroborated with data disseminated by the american association of suicidology (aas; drapeau & mcintosh, 2015a , 2015b , 2015c , also obtained directly from the cdc's wisqars and nvsr, at which time small discrepancies were located in regards to number of suicide deaths but these differences did not alter the suicide rates as a measure of deaths per 100,000 individuals. in any situation in which differences were found, wisqars data was utilized rather than those reported in a secondary fashion by aas. demographic variables via wisqars are limited but include injury fatalities of individuals from all demographic categories. homicidal injury fatalities were not included, which account for a smaller percentage of injury fatalities each year than suicide and unintentional injury fatalities deemed nonsuicidal. data are reported in total numbers as well as by age group but this study did not look specifically at age groups when comparing the fatality groups. however, crude rates of injury fatalities from 2012-2016 by age group are illustrated in figure 1 . ethnicity and sex were investigated to the degree possible within the database, as ethnicity is associated with health disparities and causes of death. wisqars data included caucasian, african american, american indian, and asian/pacific islander ethnic groups, allowing for comparisons beyond crude numbers and rates. a specific latinx group was not available through this database. education was also not stratified and results in a limitation to subsequent interpretations. this data set, over the five-year span of 2012-2016, included 213,726 deaths attributed to suicide, 702,176 deaths attributed to unintentional injuries (i.e., motor vehicle accidents, assault, falls, poisoning), and 24,533 deaths attributed to undetermined injurieseach group being mutually exclusive and falling under the cdc's broader spectrum of fatal injuries. also included was the total injury fatality count for each year, which would include the noted causes as well as homicide and other causes ( table 1 ). the fatality rates per 100,000 individuals for each year were also organized, illustrating annual increases in both suicide and unintentional injury fatalities but variability in undetermined injury fatalities ( table 2) . there was a mean rate change of 0.25% in suicide fatalities and unintentional injury fatalities exhibited a mean rate change of 2.30%. there existed a mean rate change of undetermined injury fatalities of 0.125%. therefore, the average rate change was nine-fold greater for unintentional injury fatalities than suicide fatalities. to corroborate this by comparing rates from 2012 and 2016 alone, the suicide fatality rate rose by 1.0% while the unintentional injury fatality rate rose by 9.2%. pearson correlations suggested a statistically significant association between the average rates of suicide fatalities and unintentional injury fatalities from 2012-2016 (p = .024) but neither group was associated with average rates of undetermined fatalities. when reviewing crude death counts across all five years, the association remained significant between these two groups (p = .015) and became significant between unintentional injury fatalities and undetermined injury fatalities (p = .028). interestingly, comparison of rate changes from 2012 to 2016 did not reveal statistically significant associations between groups, not even between suicide rate change and unintentional injury rate change (p = .089). caucasian males are reported as those with the highest rates of suicide in the u.s. by a (reger, stanley, & joiner, 2020) . while suicide has remained the tenth-leading cause of death in the u.s., it may very well increase in the ranks along with covid-19, rising above deaths due to kidney disease and other causes of death (drapeau & mcintosh, 2020) . this analysis discovered that suicide fatality rates are strongly associated with unintentional injury fatality rates, the latter of which are deemed nonsuicidal in nature. therefore, it would be suspected, ceteris paribus, that rate changes over five years would follow suitthis was not found to be the case. instead, there must be extraneous variables impacting the degree to which injury fatalities are being deemed suicidal and nonsuicidal. over the course of five years, suicide fatalities have remained fairly consistent relative to total u.s. population deaths while there has been an ongoing increase in unintentional injury fatalities relative to this same population. when considering confounding, age, educational attainment, and time of year are three possibilities that were not included in this retrospective study. it will be important for future studies to focus more specifically on these variables, as both young and older ages are associated with risk of falls and educational attainment is associated with socioeconomic status, ethnicity, and other important variables. it may also be speculated that suicide deaths are underreported or, more likely, misreported as unintentional injuries. there may exist sociopolitical pressures involved, including an understandable ethical concern with reporting a suicide when intention is unclear. previously noted causes of death such as poisoning (general), suffocation, and drowning that may be misrepresented following autopsy, should the psychological and psychiatric history not be considered or, conversely, regarded as a requirement to verify suicides. therefore, these intentions should be thoroughly reviewed by those certified to engage in these investigations to better serve not only families of decedents but the research community striving to reduce injuryrelated deaths both suicidal and nonsuicidal in nature. in the investigation of deaths, it is critical to question the cause of death if intention is unclear. psychological autopsy should play a more universal role in these situations in an effort to better represent the suicide deaths occurring in the u.s. this standardized technique requiring specialized training offers direct exposure to data that can aid in determining whether or not a suicide death was intentional from the perspective of the decedent (cavanagh et al., 2003) . while this may not always be the case, evidence related to behaviors of suicide decedents prior to death suggests that there will exist specific antecedents (nock et al., 2017) , better informing medical examiner reports that may otherwise label the death an unintentional injury, overdose, drowning, or other causes of death. in doing so, the epidemiological aspect of suicide can proceed with fewer inaccuraciesa necessity if the field is to move toward metadata and machine learning techniques at a population level. several limitations are present, as this is a retrospective analysis of cdc wisqars data and is limited by the demographic information available in the public domain, introducing confounding. misclassification can occur in respect to groups (e.g., ethnicity, age, injury type) and the level of evidence derived from retrospective studies of this kind serves as a limiting factor that would not be of concern with other study designs. secondly, the database utilized inadequately integrated latinx groups, significantly limiting the study's ability to report on this marginalized group. third, educational attainment is a component excluded from the dataset that would further inform interpretation. fourth, the causes of nonsuicidal unintentional fatalities are highly variable across age groups with some of these causes having no overlap across age groups. this prevented a deeper analysis of causes that may be reported higher as a whole. further, it is not possible to determine the specific factors noted that are impacting these findings due to the complex nature of death reporting by individual states and the general multitude of possibilities. in spite of the confronted limitations, injury fatalities, including suicide, are relatively common occurrences. this offers a larger sample size that can offset some of the limitations posed by retrospective studies. wisqars is a commonly-utilized database that offers the opportunity to view data in various forms and analyze to the degree possible. while confounding cannot be avoided, this study illuminates several areas for growth and improvement in suicide research, such as factors related to ethnicity, sex, death reporting, and how between-group data suicide & unintentional injury fatalities 14 should be reported to ensure clarity in clinical settings. in the absence of important data points and adequate reporting, clinicians are limited in their abilities to target those at greatest risk. there exist clear associations between unintentional injury fatalities and suicide deaths, with interesting rate discrepancies over the course of time that may be related to confounds noted in this article, as well as others that may not be on our radars. importantly, these findings highlight areas in need of improvement. inaccurate information on the global cause of death posed by suicide may result in future research efforts in epidemiology and prevention being misguided and, worse, inhibited from substantial progress in the areas of secondary and tertiary prevention methods. the accurate reporting of injury-related deaths is critical to future suicide research so that it may reflect the true nature of suicide deaths occurring in societythis is arguably necessary if we are to offset its current upward trend. fewer, ensuring that privacy and confidentiality are maintained. human and animal rights in informed consent: all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. cited articles contain studies with human and/or animal work approved by institutional review boards prior to publication. data use: data use restrictions are noted on the site to be utilized (https://wisqarsviz.cdc.gov:8006). "the public health service act (42 u.s.c. 242m(d)) provides that the data collected by the national center for health statistics (nchs) may be used only for the purposes for which they were obtained; any effort to determine the identity of any decedent, or to use the information for any purpose other than for health statistical reporting and analysis, is against the law." guidelines pertaining to confidentiality in the context of publicly-available archival data require exclusion of any counts of human subjects ≤ 10 from both basic reports of raw data as well as from any subsequent analyses. table 4 . wisqars injury fatality rates by ethnicity (per 100,000 people). risk-taking behavior and suicidality: the unique role of adolescent drug use detecting potential underreporting of suicide ideation among u.s. military personnel risktaking behaviors and stressors differentially predict suicidal preparation, non-fatal suicide attempts, and suicide deaths psychological autopsy studies of suicide: a systematic review comparison of vital statistics definitions of suicide against a coroner reference standard: a population-based linkage study animal models to improve our understanding and treatment of suicidal behavior surveillance for violent deaths -national violent death reporting system, 16 states temporal patterns of road traffic injuries in iran seasonal differences in psychopathology of male suicide completers using national inpatient death rates as a benchmark to identify hospitals with inaccurate cause of death reporting -missouri serotonergic medication enhances the association between suicide and sunshine ptsd symptoms and suicide risk in veterans: serial indirect effects via depression and anger suicide and agency: anthropological perspectives on self-destruction, personhood, and power psychological autopsy study comparing suicide decedents, suicide ideators, and propensity score matched controls: results from the study to assess risk and resilience in service members (army starrs) anomalously warm temperatures are associated with increased injury deaths prolactin and thyroid hormone levels are associated with suicide attempts in psychiatric patients bereavement after the suicide of a significant other seasonality of causes of death suicide mortality and coronavirus disease 2019 -a perfect storm? jama psychiatry. advance online publication risk factors of a suicide reattempt by seasonality and the method of a previous suicide attempt: a cohort study in a japanese primary care hospital the frontiers of suicide predicting suicide ideation in the military: the independent role of aggression seasonal patterns of traumatic brain injury deaths due to traffic-related incidents in the slovak republic risk factors associated with attempted suicide among us army soldiers without a history of mental health diagnosis suicidal ideation in college students varies across semesters: the mediating role of belongingness under reporting of suicide ideation in us army population screening: an ongoing challenge integrating medical examiner and police report data: can this improve our knowledge of the social circumstances surrounding suicide? conflicts of interest/competing interests: [redacted] is supported by the alfred adler scholarship. no other funding has been received. the author discloses no conflicts of interest informed consent: the relevant institutional review board (irb) deemed this analysis exempt. cdc's wisqars data is publicly-available data for the use in secondary analyses jack c. lennon was responsible for the initial conceptualization, data curation, formal analysis, project administration, writing, and editing of this original manuscript. ☒ the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐the authors declare the following financial interests/personal relationships which may be considered as potential competing interests: caucasian african american american indian key: cord-354475-im2py2or authors: ioanna, giannopoulou; vasiliki, efstathiou; georgia, triantafillou; panajota, korkoliakou; athanasios, douzenis title: adding stress to the stressed: senior high school students’ mental health amidst the covid-19 nationwide lockdown in greece. date: 2020-11-06 journal: psychiatry res doi: 10.1016/j.psychres.2020.113560 sha: doc_id: 354475 cord_uid: im2py2or the two-year preparation for the national university entrance exams in greece is one of the most trying periods in a young person's life, physically and emotionally. the present study reports the results from 442 last year senior high school students who completed an online survey (16-30 april 2020) concerning the lockdown impact on their mental health. overall, the rate of positive screen for depression (phq-9 score ≥ 11) significantly increased from 48.5% to 63.8% and of those scoring within severe depression range (phq-9 ≥20) from 10% to 27%; for anxiety (gad-7 score ≥ 11) increased from 23.8% to 49.5% and of those scoring within severe anxiety range (gad-7≥17) from 3.8% to 20.5%. after taking sex and baseline (one month prior to the lockdown) levels of depression and anxiety into account, the level of lockdown experienced distress was predictive of depression and anxiety levels in time of home confinement, accounting for about 30% of variance in symptoms severity scores. although our results may be subject to sampling and recall bias, the unexpectedly high rates of anxiety and depression warrant an urgent call to action aiming at mitigating and managing mental health risks of senior high school students in future waves of pandemic. on march 11th, who declared the disease caused by covid-19 a pandemic due to its widespread and rapid rate of transmission. the first covid-19 case was diagnosed in greece on february 26th. on march 10th, with officially 89 confirmed covid-19 cases and 0 deaths, the greek government implemented national school and university closures and following this, new measures were gradually introduced, every 2-3 days, to mitigate the risk of exponential virus transmission. on march 23rd with 695 confirmed cases and 17 deaths, nationwide lockdown (i.e. restriction of movement, whereby citizens could leave their house only for specific reasons and with a special permit) was enforced as a key emergency public health measure (giannopoulou & tsobanoglou 2020) . studies have shown that prolonged school closure and home confinement during a disease outbreak might have negative effects on children's physical and mental health (for review guessoum et al., 2020) but no studies to date have reported on mental health of final year high school students facing university entrance exams. successful admission to a higher education institution in greece is determined through the combination of: (a) the candidate's score on the national higher education entrance exams, known as panhellenic exams, administered by the ministry of education, (b) the candidate's choices (by order of preference) of desired degree courses and academic institutions, and (c) the number of places available in each academic department. greek society places a high value on tertiary education, and psychological pressure for success in university entrance exams is great given that it is perceived as having major consequences for determining the young person's future life and career prospects (oecd, 2018) . the two-year preparation for the panhellenic university entrance exams is one of the most trying periods in a young person's life, physically and emotionally. almost every student is overburdened by a considerable workload and long hours of study due to enrollment in two parallel educational systems -regular school and private coursework delivered by a cram school, so called "frontistirio" and/or individual tutoring (giannopoulou, 2019; liodaki & liodakis, 2016) . the pressure to score high in these exams in combination with the greek society's view that every student should obtain a university degree makes the panhellenic exams a highly stressful and often traumatic event for many greek youngsters, and particularly for those who wish to be admitted to a highly ranked academic institution (e.g. medicine, law, electrical & computer engineering). the money invested by parents in their child's extra private tuition adds more financial strain to the family, raises parental expectations and puts some young people under enormous stress to succeed. this year, students were faced with abrupt coronavirus-related disruption adjustment in their daily life and new challenges, including the adaptation to the sudden switch to online learning, combined with uncertainty about the timing of the exams, the conditions under which these will take place, the exact material they will be tested on, and the date of any return to school. the aim of the present study was to examine the impact of the nationwide lockdown on the levels of anxiety and depression among last year senior high school students preparing for the upcoming panhellenic university entrance exams. we expected to find an increase in anxiety and depression scores from one month prior to the lockdown to past two weeks during the lockdown. we anticipated that the level of lockdown experienced distress impinging on students' preparation for national exams would be significant predictors of anxiety and depression levels during the lockdown. a brief survey was constructed and made available in electronic form, using a secure web-based application redcap (research electronic data capture) hosted at the national and kapodistrian university of athens. self-selection sampling procedure was followed; the study with its link was publicized, through social media and websites of educational news, but also through sending an email invitation to students from cram schools (frontistiria). students were informed about the goals of the study, its rationale, and the process by which data would be collected, and about confidentiality and anonymity of their voluntary participation. for those under 18 years of age informed parental consent was sought, in addition to the young person's consent. young people were given an option to contact our service through e-mail or telephone if they felt they needed guidance/psychological support. the study was approved by the ethics committee of the attikon university general hospital. data was collected over two weeks from april 16 to april 30. a total of 459 students completed the survey; 4 students who reported that they will not take part in the panhellenic exams and 13 students who indicated that they were sitting the exams for the second time were excluded from the data analysis, as the numbers were too low to allow for separate groups analysis. only one student requested psychological help via sending an e-mail to our service. the questions were presented in four sections: (a) demographic characteristics, (b) anxiety and depressive symptoms over the first two weeks of february (prior to nationwide lockdown -baseline); (c) anxiety and depressive symptoms during the past two weeks (during lockdown -current), using the greek versions of gad-7 and phq-9 (the patient health questionnaire screeners, www.phqscreeners.com); (d) distress experienced during lockdown. anxiety was measured using the 7-item generalized anxiety disorder scale (gad-7), which has been validated in adolescent populations (mossman et al., 2017; tiirikainen et al., 2019) . the respondents were asked to indicate on a 4-point likerttype scale (0= not at all, 1 = several days, 2= over half of the days, 3=nearly every day) the frequency of each anxiety symptom over two weeks the scores on these seven items were summed to generate the total anxiety symptoms severity score (range 0-21). the internal consistency of the gad-7 in the present study was good in the total sample (α = 0.81 for the baseline -prior to the lockdown), and α = 0.88 for the current -during the lockdown) measure, with cronbach's alpha ranging from 0.82 to 0.91 in the sex subgroups. consistent with research literature we used a gad-7 score of 11 or greater as indicating a positive screen for anxiety. in addition, we applied the cut-off score of 17 as indicating severe anxiety, which coincided with ≥96th percentile at baseline. this is a 9-item self-report questionnaire assessing depression symptoms over the past two weeks; the phq-9-modified includes minimal adjustments to the original phq-9 (spitzer, williams, & kroenke, 1999) to incorporate characteristics of depression in adolescents and age-appropriate language. specifically, the phq-9-modified includes irritability in the item assessing depressed mood, and weight loss in the item assessing appetite. throughout this paper the abbreviation "phq-9" is used to indicate the phq-9-modified. the phq-9 has been validated among adolescents across various cultures and settings (adewuya et al., 2006; burdzovic andreas and brunborg, 2017; fatiregun and kumapayi, 2014; richardson et al., 2010; tsai et al., 2014) . each item is rated on a 4-point scale ranging from 0 ("not at all") to 3 ("nearly every day"). in our study, cronbach's alphas were 0.86 prior to the lockdown and 0.90 during the lockdown; 0.86 and 0.91 respectively for male sex, and 0.85 and 0.89 respectively for female sex. consistent with research literature we used a phq-9 score of 11 or greater as indicating a positive screen for depression. in addition, we applied the cut-off score of 20 as indicating severe depression, which coincided with ≥90th percentile at baseline. for the purpose of the study we developed a brief measure of distress experienced during lockdown, impinging on the students' preparation and revision for the exams. respondents were asked to rate on a 5-point scale (1=not at all, 2= slightly, 3=moderately, 4=very, 5= extremely) how often, since the nationwide lockdown, they had been experiencing heightened anxiety/insecurity about the panhellenic exams, feeling loneliness, feeling boredom, feeling abandoned by their teachers, feeling estranged from their friends/school peers, feeling worried about future, being troubled by negative thoughts/images, experiencing difficulty to feel close to others, experiencing a fear of death. the scores on these nine items were summed to generate the total lockdown-experienced distress score, which ranges from 9 to 45. the cronbach's alpha of this measure for the entire sample was 0.82, indicating good internal consistency. descriptive statistics were calculated and presented as mean and standard deviation (m, sd) for continuous measures and absolute and relative (%) frequencies for categorical variables. simple comparisons between groups were performed using independent samples t tests for quantitative variables and the chi-squared test for categorical variables. a two-way mixed analysis of variance (anova) was performed to assess the within-person changes, i.e. prior to the lockdown (baseline) versus past two weeks (current) and the main effect of sex (male vs female) on the levels of anxiety and depression symptoms. in addition, mcnemar test was used to examine within individual changes in symptom severity according to measures' cut off points. two-stage multiple regression analyses were carried out to identify significant predictors of self-report gad-7 and phq-9 current scores (dependent variables). independent predictor variables included in the analysis were sex, baseline depression symptoms severity and baseline anxiety symptoms severity (stage one) and lockdown distress measure (stage two); interactions were tested and found non-significant. prior to conducting the multiple regressions, the relevant assumptions of this statistical analysis were tested, i.e. correlations between independent variables, the collinearity statistics (i.e., tolerance and vif), residual and scatter plots, indicating whether the assumptions of normality, linearity and homoscedasticity were all satisfied. all the analysis was done at 95% level of confidence using spss software version 24. a two-way mixed anova revealed a significant increase in gad-7 and phq-9 severity scores from one month prior to the lockdown to during the lockdown period, with girls scoring significantly higher than boys at both points in time (see table1) . no significant interaction was found for either measure, f (1,436) = 0.918, p=0.339 for gad-7 and f (1,433) =0.058, p=0.809. table 2 shows the frequency of positive screen for anxiety and depression, using cut off scores. the proportion of all respondents who screened positive for anxiety (gad-7 ≥ 11) increased from 28.3% before the pandemic to 49.5% for the time of home confinement (mcnemar test p <0.0001) and of those scoring within the severe anxiety range (gad-7≥17) increased from 3.8% to 20.5% (mcnemar test p <0.0001). the proportion of all respondents who scored above the phq-9 cut off 11 or greater indicating positive screen for depression increased from 48.5% before the pandemic to 63.8% for the time of home confinement (mcnemar test p <0.0001) and of those scoring within the severe depression range (phq-9 ≥20) increased from 10% to 27% (p<0.001). the proportion of respondents who reported having thoughts that they would be better off dead, or of hurting themselves in some way increased from 25.9% before the pandemic to 29.7% during the lockdown period (mcnemar test p <0.05). more specifically, the proportion of those who reported having these thoughts nearly every day increased from 6% before the pandemic to 11.1% during the lockdown. a two-stage multiple regression was conducted with depression symptoms severity score as the dependent variable. sex, baseline depression symptoms severity score and baseline anxiety symptoms severity score were entered at stage one of regression and lockdown experienced distress measure was entered at stage two (see table 3 ). in relation to anxiety symptoms, the multiple regression revealed that at stage one, female sex, baseline depression symptoms severity score and baseline anxiety symptoms severity score contributed significantly to the regression model, f (3,434) = 54.917, p<0.001, and accounted for 27.2% of the variation in gad-7 scores during the lockdown period. introducing the lockdown experienced distress score explained an additional 29.6% of variation in gad-7 scores and this change in to the best of our knowledge this is the first study reporting data concerning the impact of the nationwide lockdown on the mental health of last year senior high school students preparing for the national university entrance exams in greece. the results indicate a substantial and worrying increase in anxiety and depression symptoms from before the covid-19 outbreak to the period of nationwide lockdown. the high rate of 48.5% of positive screen for depression before the pandemic found in our sample is unprecedented in greece and may reflect heightened exam-related academic pressure linked to uncertainty about securing a university placement, and pressure relating to family and social expectations, as the exams approach. previous field studies in greece that have looked at the epidemiology of depressive symptoms among senior high school students reported prevalence rates of depression ranging from 17.4% (magklara et al, 2015) to 26.2% (lazaratou et al., 2010) ; however, neither study has provided prevalence figures for adolescents facing university entrance exams. research in countries with similar educational structures (e.g. korea, turkey) has reported comparable depression rates in this population group (yildirim et al., 2007; lee & larson, 2000) . the rates of positive screen for depression and anxiety during the lockdown increased significantly to 64% and 50% respectively and were similar to those reported for the senior grade three students during the covid-19 outbreak in china, i.e. 60% for depression and 53% for anxiety (zhou et al., 2020) . the prevalence rates of severe depressive symptoms (phq-9 score ≥ 20) and severe anxiety symptoms (gad-7 score ≥ 17) during nationwide lockdown are staggering, as these increased from 10% before the pandemic to 27% for depression and from 3.8% to 20.5% for anxiety. the alarming rates of self-harm/suicidal thoughts merit attention, considering that the proportion of the participants who reported during the past two weeks having these thoughts increased from 26% before the pandemic to almost 30% during the lockdown period; and from 6% to 11.1% respectively with regards to having these thoughts nearly every day. the latter findings may be comparable with those reported in a recent study of university students' mental health during the nationwide lockdown in greece, whereby 9.7% of the sample reported currently thinking of committing suicide and doing some specific plans on how to do it, amounting to an almost 8-fold increase in suicidal thoughts (kaparounaki et al., 2020) . as expected, higher levels of depressive and anxiety symptoms prior to pandemic were associated with a further increase in symptomatology, but the impact of distress experienced during the lockdown was found to be the most robust predictor for a poorer mental health. after taking sex, baseline (one-month prior to pandemic) levels of depression and anxiety into account, the level of distress experienced during the lockdown was predictive of depression and anxiety levels in time of home confinement, accounting for about 30% of variance in symptoms severity scores. the findings of this study should be interpreted considering several important limitations in its design. first, the data was collected via online survey with social media and websites of educational news as the primary avenue for promotion. as such, random sampling did not occur which may have introduced sampling bias into the survey. the number of young people who saw the survey and chose not to participate could not be determined; however, it is plausible that those with a pre-existing interest in mental health and/or experiencing psychological distress would be more likely to respond to the survey, which may have inflated the rates of depression and anxiety. however, this limitation applies to most of the mental health surveys of covid-19, which have mostly used web-based convenience samples (pierce et al., 2020) . second, the measures, i.e. gad-7 and phq-9, have not been validated in greek adolescents' population. however, both demonstrated high internal consistency in the entire sample and in both sexes. third, both self-reported and retrospective rating of symptoms, prior and during the lockdown, are subject to recall bias. fourth, the estimates of anxiety and depression based on cut-off values on the self-report questionnaires may not be consistent with those based on clinical structured interviews. fifth, the use of the lockdown experienced distress measure developed for the purpose of the present study, despite its good internal consistency, being a non-validated previously measure may compromise the quality of the results. however, the within subjects' comparison of prior to (baseline) and during (current) the lockdown gad-7 and phq-9 scores supports our conclusion that the observed significant increase in depressive and anxiety symptoms was lockdownrelated. moreover, 30% of the variability in depression and anxiety scores in time of home confinement was explained by distress experienced during the lockdown. sixth, important predisposing and mediating factors, such as stressful and traumatic experiences prior to the pandemic, family/parental stress (e.g. related to financial difficulty, living conditions, social and interpersonal changes, family functioning) considered important predictors of psychological and mental health well-being were regrettably not assessed. although our results may be subject to sampling and recall bias, the unexpectedly high rates of anxiety, depression and self/harm suicidal thoughts warrant an urgent call to action. identifying and monitoring young people with such vulnerabilities, especially in time of preparation for the exams, is of paramount importance. to mitigate the mental health impact of potential future restrictions measures in response to the ongoing pandemic, the ministry of education, the community primary health services, the educators, and parents need to be aware of the downsides of the home confinement situation in order to address more effectively the issues related to added stress experienced by already stressed young people preparing for highly competitive university entrance exams. the covid-19 outbreak in greece may be an opportunity to look for new models to manage more effective education and to tackle the many flaws underpinning the system of the panhellenic university entrance exams. future studies should employ qualitative mixed methods design to explore the lived lockdown-related experiences of the students, their parents and their educators in the context of preparation for highly competitive exams. this approach will provide an important insight into the interplay between risk factors and buffers affecting young peoples' mental health outcomes and will inform interventions aiming at mitigating and managing mental health risks in future waves of pandemic. authors have no conflicts of interest to declare. i.g., g.t. and p.k. designed the study. v.e. designed and built the online data base for data collection. i.g. and v.e. analyzed the data. i.g. and v.e. drafted the manuscript, and g.t. and a.d. provided critical revisions. all authors approved the final manuscript for submission. validity of the patient health questionnaire (phq-9) as a screening tool for depression amongst nigerian university students depressive symptomatology among norwegian adolescent boys and girls: the patient 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students preparing for national university entrance examination in turkey prevalence and socio-demographic correlates of psychological health problems in chinese adolescents during the outbreak of covid-19 key: cord-341038-lomaz6pc authors: odriozola-gonzález, paula; planchuelo-gómez, álvaro; irurtia, maría jesús; de luis-garcía, rodrigo title: psychological effects of the covid-19 outbreak and lockdown among students and workers of a spanish university date: 2020-05-19 journal: psychiatry res doi: 10.1016/j.psychres.2020.113108 sha: doc_id: 341038 cord_uid: lomaz6pc the aim of this study was to analyze the psychological impact of covid-19 in the university community during the first weeks of confinement. a cross-sectional study was conducted. the depression anxiety stress scale (dass-21) was employed to assess symptoms of depression, anxiety and stress. the emotional impact of the situation was analyzed using the impact of event scale. an online survey was fulfilled by 2530 members of the university of valladolid, in spain. moderate to extremely severe scores of anxiety, depression, and stress were reported by 21.34%, 34.19% and 28.14% of the respondents, respectively. a total of 50.43% of respondents presented moderate to severe impact of the outbreak. students from arts & humanities and social sciences & law showed higher scores related to anxiety, depression, stress and impact of event with respect to students from engineering & architecture. university staff presented lower scores in all measures compared to students, who seem to have suffered an important psychological impact during the first weeks of the covid-19 lockdown. in order to provide timely crisis-oriented psychological services and to take preventive measures in future pandemic situations, mental health in university students should be carefully monitored. • college students reflected a possible psychological impact of the lockdown. • symptoms of common mental health disorders were reported by 20-35% of respondents. • around the half of respondents presented moderate to severe impact of the outbreak. • students from the engineering and architecture area showed lower symptomatic scores. • mental health from students should be monitored to mitigate the impact of the crisis. situation was analyzed using the impact of event scale. an online survey was fulfilled by 2530 members of the university of valladolid, in spain. moderate to extremely severe scores of anxiety, depression, and stress were reported by 21. 34%, 34.19% and 28 .14% of the respondents, respectively. a total of 50.43% of respondents presented moderate to severe impact of the outbreak. students from arts & humanities and social sciences & law showed higher scores related to anxiety, depression, stress and impact of event with respect to students from engineering & architecture. university staff presented lower scores in all measures compared to students, who seem to have suffered an important psychological impact during the first weeks of the covid-19 lockdown. in order to provide timely crisis-oriented psychological services and to take preventive measures in future pandemic situations, mental health in university students should be carefully monitored. keywords: university students, anxiety, stress, depression, psychological impact the novel coronavirus disease was firstly detected in wuhan (hubei province, china) in december 2019. from that moment, it began to spread first in china, and soon afterwards throughout the world. confirmed cases and deaths grew rapidly, and on april 5th there were more than 1,200,000 confirmed cases worldwide and more than 68,000 people had died from it (johns hopkins university & medicine, 2020) . this situation has produced a notable emotional impact on medical workers and the general population, with important symptoms of anxiety, stress and depression (kang et al., 2020; wang et al., 2020) . on that same date, 130,759 covid-19 cases had been registered in spain, making it the third country in the world with the most people affected by this pandemic. in response to this situation, between march 9th and 13 th there was a progressive closure of schools and universities. on march 14th, the spanish government declared a nationwide state of alert and population lockdown was imposed as of march 16th. for many spaniards, this is the first experience of an emergency with an imperceptible agent, leading to great uncertainty and significant adverse consequences for mental health (hawryluck et al., 2004; shigemura et al., 2020) . although the overall impact on education and mental health of the university environment is still unknown, it is expected to be very considerable (araújo et al., 2020; sahu, 2020) . considering the usual high incidence of emotional disorders in university students, it can be expected that the current situation may cause a notable impact on this population (auerbach et al., 2016; bruffaerts et al., 2018; hunt and eisenberg, 2010) . for instance, in a recent study focusing on chinese medical college students, higher levels of anxiety were associated with factors strongly related to covid-19, such as acquaintance with a covid-19 diagnosed patient (cao et al., 2020) . likewise, data from international students have shown an increase in concerns not only for their education, but also for the well-being of their families in case of their return home because of suspended in-person classes (zhai and du, 2020) . given the expected impact of the situation on this community, it is crucial to analyze the experience of members of the university community during the covid-19 crisis and confinement in order to develop measures and implement psychological interventions properly adjusted to this situation. that may help mitigate the possible adverse effects on education, work and mental health among the university members. the purpose of this study was to analyze the psychological symptoms on the members of university of valladolid, in spain, during the outbreak of the covid-19. every member of the university of valladolid living in spain at the time of the study was eligible for participation in this study. an anonymous internet survey was announced through the communication channels of the university of valladolid, a regional tv station and social media. ethics approval was obtained from the research ethics board of the university of valladolid. a web-based survey composed of 66 multiple-choice questions was launched on march 28th, 2020, and remained open during 8 days. the survey took approximately 10 minutes to complete, and included questions referred to demographical data, personal situation during the confinement, present and/or past psychological/psychiatric treatment, present intake of psychoactive medication, perceived impact of the confinement on personal and social relationships, self-reported concern about the social and economic situation caused by the crisis and its impact on the health of oneself, partner, parents, children and other family and friends. moreover, questions related specifically to the university of valladolid were included for the university students and workers. they were asked about their role at the university (student, faculty member or academic staff, or administrative staff). students and faculty members or academic staff were asked about their area of study or expertise. the emotional impact and psychological symptoms associated with confinement due to the covid-19 crisis were evaluated using two scales: depression anxiety stress scale (dass-21; antony et al., 1998) and the impact of event scale (ies; horowitz et al., 1997) . the dass-21 is a 4-point likert-type scale (3 = applied to me very much or most of the time; 0 = did not apply to me at all) that measures the negative emotional states experienced during the last week through 21 items. we administered the spanish version of the dass-21 (daza et al., 2002) . it has shown a hierarchical factor structure with three first-order factors (depression, anxiety, and stress) and a second-order factor that is an overall indicator of emotional symptoms (ruiz et al., 2017) . the dass-21 has also shown good internal consistency and convergent and discriminant validity. the ies is a 4-point likert-type scale (0= not at all, 1=rarely, 3=sometimes, 5=often) that assesses subjective distress resulting from a traumatic life event through 15 items. it contains two subscales: intrusion (intrusive thoughts, nightmares, intrusive feelings and imagery, dissociative-like re-experiencing) and avoidance (numbing of responsiveness, avoidance of feelings, situations and ideas). we administered the spanish version by baguena et al. (2001) , which has shown good psychometric properties. slight adaptations were performed from this version (changing verbal tenses where needed) to account for the nature of the event explored. a cut-off of the ies ≥26 was used to reflect moderate to severe impact. generalized linear models (glm) with a gaussian distribution were employed to analyze the association between the dass-21 and ies scores with each of independent variables described at the survey instrument subsection. glm models were also applied to the self-reported concern about the health of different family members and friends, and about the social and economic situation. the independent variables were the same as for the previous glm. the final multivariate glm was selected using the akaike's information criterion (aic) and an automatic stepwise strategy, with forward and backward steps. the model with the lowest aic was automatically selected. diverse multivariate models were obtained to consider the diverse variables specific to each university group. p-values below 0.05 were considered to be statistically significant. the analysis was performed using r statistical software package, version 3.5.2. the survey was completed by a total of 3,707 participants, among which 2,530 belonged to the university of valladolid and are thus the sample considered in this study. there was a 66.1% of female participants, and ages ranged between 18 and 70 years (m = 27.9, sd = 12.4). 76.8% of the participants were students, 9.8% administrative staff and 13.4% faculty members and academic staff (excluding phd students). the qualitative characteristics of the final survey respondents are summarized in table 1 , whereas their characteristics related to their situation in the university of valladolid are described in table 2 . the mean values and standard deviations for each of the dass-21 subscales were 5.52±4.92 for depression, 3.34±3.87 for anxiety and 6.81±4.72 for stress. figure 1 shows the distribution of dass-21 mean scores by area of study or research area (students and faculty members or academic staff). figures 2-4 show the proportion of university students that fall within each of the groups that are usually considered for this instrument, considering their area of study. in the three subscales, students from the e&a area were those with the highest proportion of subclinical scores and lowest of severe and extremely severe scores. on the other hand, students from the a&h and ss&l areas were those with the lowest proportion of subclinical anxiety and depression scores, with a similar proportion to the sciences area for stress. univariate glm coefficients for the specific university characteristics are shown in table 3 . supplementary figures 1-2 show the distribution of dass-21 mean scores by university group and year of study (including master and phd students) excluding the last two years, which in the university of valladolid only include architecture and medicine students. univariate coefficients for the other characteristics are shown in supplementary table 1. significant higher depression, anxiety and stress scores were observed in students with respect to university workers. in addition, scores were significantly higher in undergraduate students compared to master students for depression, anxiety and stress, and also compared to phd students for stress. for the three subscales, significant lower scores were found in e&a students compared to the students from the other areas, except for the depression subscale in students from the hs area. undergraduate students at the sixth year of their studies (which include only medicine students) presented significant lower depression and stress scores compared to first year students, and significant lower depression scores were also found for fourth year students with respect to first year. faculty members and academic staff from the a&h area presented significant higher scores with respect to the e&a area for the three subscales, and workers from the hs area also showed significant higher anxiety scores compared to the e&a area. after adjusting for multiple covariates, administrative staff showed significant lower anxiety scores compared to students, and faculty members and academic staff showed significant lower depression scores compared to students. significant lower stress scores were found in master compared to undergraduate students. significant higher anxiety scores were found in a&h and ss&l with respect to e&a students, and also higher depression scores in a&h compared to e&a students. faculty members and academic staff from the a&h area also showed significant higher depression scores compared to those in e&a. the complete multivariate model can be seen in supplementary table 2 . around 12.5% of the respondents showed scores related to severe symptoms with the ies instrument, and around 75% of the sample presented mild or moderate symptomatic levels, with relatively higher avoidance than intrusion scores. univariate glm coefficients for the specific university characteristics are shown in table 4 . univariate coefficients for the other characteristics are shown in supplementary table 3 . with respect to the students, significant higher intrusion and avoidance scores were observed compared to faculty members and academic staff, and only higher avoidance scores compared to administrative staff. master students showed significant lower intrusion and avoidance scores compared to undergraduate students, and lower avoidance scores in phd compared to undergraduate students. significant lower intrusion and avoidance scores were observed in e&a students in comparison with the other four areas. sixth year undergraduate students (medicine students only) presented significant lower avoidance scores with respect to first year students. e&a faculty members and academic staff showed significant lower intrusion and avoidance scores in comparison with the other areas, except intrusion scores compared to the sciences area. after adjusting for multiple covariates, administrative staff showed significant lower avoidance scores compared to students, and faculty members and academic staff showed significant lower intrusion scores compared to students. significant higher intrusion and avoidance scores were found in a&h and ss&l with respect to e&a students. the same result was also observed in faculty members and academic staff. within this group, workers from the sciences field showed higher avoidance scores in comparison to those in e&a. the complete multivariate model can be seen in supplementary table 4 . the concern scores are summarized in table 5 . univariate glm coefficients for the specific university characteristics are shown in tables 6-7. university workers (both faculty members or academic staff and administrative staff) presented generalized significant higher concern scores with respect to students, except for their concern about relatives' health. generalized significant higher concern scores were found in a&h and ss&l compared to e&a students. some concern scores were significantly lower in undergraduate students compared to studies different to phd and master (labelled as other studies), and in first year students compared to students from higher years. significant higher concern score about social situation was found in a&h in comparison with e&a faculty members and academic staff. univariate models for other characteristics are shown in supplementary tables 5-6. adjusting by multiple covariates, some of the univariate identified differences remained significant, such as the differences between students from e&a with respect to a&h and ss&l field, and the differences between workers and students. the multivariate models are shown in supplementary tables 7-8. the covid-19 outbreak has prompted most countries opt for population confinement and social distancing measures as a way to control the spread of the virus. however, important psychological effects have been pointed out in previous confinement experiences (hawryluck et al., 2004) . the current pandemic has already shown significant psychological symptoms related to anxiety, stress and depression wang et al. (2020) . as these authors point out, this difference in prevalence may be due to the specific evaluation of the impact of the event by ies versus a non-specific evaluation by dass-21. regarding the different groups at the university, significantly higher depression, anxiety and stress scores were observed in students compared to the different groups of employees. the high prevalence of psychological symptoms in university students has been frequently pointed out (auerbach et al., 2016; bayram and bilgel, 2008; bruffaerts et al., 2018) . while there is evidence from several studies in which students from the hs or engineering area were found to present higher symptomatology scores than those in the humanities area (elias et al., 2011; posselt and lipson, 2016) , our results show precisely the opposite. in fact, the lowest scores are shown by e&a students and workers on all three subscales. in line with our results, the study of lipson et al. (2016) showed that a&h students have a greater tendency to develop mental illnesses compared to the other areas, such as the engineering and business students, who also seem to undergo treatment less frequently. the percentage of moderate to severe scores of the subgroups of our sample in ies also showed higher prevalence in the a&h area and lower prevalence in the e&a area, not only in the students group, but also in the group of faculty members and academic staff. specifically, 60.31% of students and 45.07% of faculty members and academic staff of a&h compared to 40.42% of students and 23.86% faculty members and academic staff of e&a showed moderate to severe ies scores. to our knowledge, this study is the first one that analyzes the impact of a major event such as the covid-19 crisis in students from different fields. a study with a large sample size performed in china obtained similar percentage of respondents with moderate or severe ies scores with respect to our study . furthermore, that study also highlights the high levels of symptomatology in students, indicating that the uncertainty and the potential negative impact on academic progress may have motivated the impact on students' mental health. however, results from another study in the general population of china, evaluated using the same instrument (ies), seem to show a much lower percentage of moderate or severe scores on the impact of the event, 7.6% (zhang and ma, 2020) . the reasons for the difference between that study and our results may perhaps be related to the considerable age difference between the respondents of both studies, with younger respondents in our case, and a significantly smaller sample size in the study on the chinese general population. in our study, by contrast, university employees from all groups showed higher concern scores than students, except for concern about relatives' health. once again, the a&h students, along with those in the ss&l areas, showed a higher level of concern than the e&a students. similarly, faculty members and academic staff in a&h had a higher concern score about the social situation in comparison with those in e&a. the presence of a more pragmatic attitude or different world viewpoints in the e&a group might account for the differential results found in this study, but more research would be needed to elucidate this issue. this study has some strengths and limitations. among the strengths, the large sample size (2530 respondents) allowed us to perform a robust analysis and extract solid tendencies and associations. also, this is an early study that offers a unique opportunity to investigate the emotional impact of the covid-19 pandemic in a university environment. it provides valuable information about the current situation useful to gain some insight about the situation in other universities or in possible future global crises. regarding the limitations, firstly, this is a cross-sectional study carried out at a spanish university under an unprecedented situation. longitudinal studies are needed to analyze the long-term impact of this situation on the psychological state of their members and to draw conclusions about the cause and effect relationships between the variables involved. secondly, we adopted a convenient online survey in only one university from spain, which may contribute to some bias in the study results. larger scale surveys in different universities should be conducted in order to extend and generalize the findings. thirdly, our results indicate the need of incorporating additional aspects in future studies. for example, it is important to explore why younger students are suffering a greater psychological impact, which could be related to factors such as their perception of the future, their way of consuming information media, etc. in conclusion, university students have been specially impacted by the covid-19 confinement. students from the ss&l and a&h fields were more affected than students from other areas, particularly with respect to e&a students. this study suggests that mental health from university students and employees should be carefully monitored during this crisis, and that universities should provide psychological services oriented and adapted to these circumstances to mitigate the emotional impact on university members. administrative staff vs. student -7.12**** -2.73**** -1.58**** -2.80**** academic staff vs. student -6.22**** -1.84**** -1.34**** -3.03**** .76** **** p < 0.0001, *** p < 0.001, ** p < 0.01, * p < 0.05 table 5 . concern for health and socio-economic situation. mean ± sd median interquartile range own health (n = 2521) 5.4 ± 2.9 5 5 partner health (n = 1624) 6.6 ± 3.0 7 5 parents health (n = 2419) 8.2 ± 2.3 9 3 children health (n = 613) 5.6 ± 3.8 6 9 other family health (n = 2489) 8.3 ± 2.2 9 3 friends health (n = 2511) 6.6 ± 2.7 7 4 social situation (n = 2503) 8.1 ± 2.2 9 3 economic situation (n = 2490) 8.2 ± 2.2 9 3 sd = standard deviation. table 6 . univariate glm coefficients associating concern with respondents characteristics related to the situation at the university of valladolid (part 1). own health parents health children health group administrative staff vs. student 1.07**** 0.95**** 0.76**** 3.57**** academic staff vs. student 0.76**** 0.62** 0.67**** 3.31**** 27 -0.32 -0.18 **** p < 0.0001, *** p < 0.001, ** p < 0.01, * p < 0.05 table 7 . univariate glm coefficients associating concern with respondents characteristics related to the situation at the university of valladolid (part 2). 0.20 0.18 0.59 **** p < 0.0001, *** p < 0.001, ** p < 0.01, * p < 0.05 psychometric properties of the 42-item and 21-item versions of the depression anxiety stress scales (dass) in clinical groups and a community sample impact of sars-cov-2 and its reverberation in global higher education and mental health mental disorders among college students in the world health organization world mental health surveys psychometric 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lancet major differences: variations in undergraduate and graduate student mental health and treatment utilization across academic disciplines competition, anxiety, and depression in the college classroom: variations by student identity and field of study the hierarchical factor structure of the depression anxiety and stress scale-21 closure of universities due to coronavirus disease 2019 (covid-19): impact on education and mental health of students and academic staff public responses to the novel 2019 coronavirus (2019-ncov) in japan: mental health consequences and target populations immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. the lancet mental health services for older adults in china during the covid-19 outbreak. the lancet addressing collegiate mental health amid covid-19 pandemic impact of the covid-19 pandemic on mental health and quality of life among local residents in liaoning province, china: a cross-sectional study álvaro planchuelo-gómez was supported by junta de castilla y león (spain) and the european social fund (id: 376062, base de datos nacional de subvenciones). this study received no specific funding. ☒ the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐the authors declare the following financial interests/personal relationships which may be considered as potential competing interests: key: cord-347513-xibx3nkd authors: meng, hui; xu, yang; dai, jiali; zhang, yang; liu, baogeng; yang, haibo title: analyze the psychological impact of covid-19 among the elderly population in china and make corresponding suggestions date: 2020-04-11 journal: psychiatry res doi: 10.1016/j.psychres.2020.112983 sha: doc_id: 347513 cord_uid: xibx3nkd abstract to understand the emotional changes in the elderly population during the pneumonia epidemic caused by novel coronavirus infection, and to lay a foundation for the study of the psychology, intervention and nursing of the elderly.a total of 1556 elderly people were selected to conduct an epidemiological survey, and standardized survey methods were used to investigate the depression screening scale (phq-9) and anxiety self-rating scale (gad-7).the anxiety and depression of different genders were different.anxiety and depression are different in different age groups.the outbreak of pneumonia caused by novel coronavirus infection has an effect on the psychology of the elderly people, resulting in anxiety and depression. since december 2019, multiple unexplained cases of viral pneumonia related to the south china seafood market have been discovered in wuhan city, hubei province, and they have been questionnaire, gad-7 questionnaire. gad-7, phq-9 all have good content validity and internal consistency reliability [1] . independent sample t test conducted on the scores of phq-9 and gad-7 in different sex groups. one-way analysis of variance conducted on the scores of phq-9 and gad-7 in different age groups. as a result, there were 578 people with emotional reactions, accounting for 37.1%, and 978 people without emotional reactions, accounting for 62.9%. comparison of the scores of phq-9 and gad-7 in different sex groups. by t test table 1 shows the difference in anxiety and depression among different sex groups.the results show that there is a significant difference in anxiety between men and women (p <0.05).there is a significant difference in the degree of depression between men and women (p <0.05). comparison of the scores of phq-9 and gad-7 in different age(y) groups. by one-way analysis of variance there is no significant difference between different age groups (p> 0.05), which may be related to there is a certain relationship between the physiological changes of the elderly and their psychological characteristics [4] . physiologically, the elderly will also experience psychological changes as their 3) the system and mechanism of psychological counseling and psychological crisis intervention for the elderly still need to be further improved to strengthen the mental health of the media and new entertainment methods education to make it easier for the elderly to accept. 4) if the emotional response is too serious, it is recommended to call the psychological assistance hotline ， online consultation or visit a professional institution。 in short, the mental health of the elderly needs more attention. when major public health emergencies, the elderly should be paid more attention to [5] , and more humane care and psychological intervention measures should be given to them. questions, targeted psychological crisis interventions to reduce the psychological harm caused by the epidemic and subsequent psychological problems。 manual of mental health rating scale a nationwide survey of psychological distress among chinese people in the covid-19 epidemic:implications and policy recommendations recommended psychological crisis intervention response to the 2019 novel coronavirus pneumonia outbreak in china: a model of west china hospital the impact of sars on the mental health of different elderly groups key: cord-273638-mmlwh87u authors: tso, ivy f.; park, sohee title: alarming levels of psychiatric symptoms and the role of loneliness during the covid-19 epidemic: a case study of hong kong date: 2020-08-23 journal: psychiatry res doi: 10.1016/j.psychres.2020.113423 sha: doc_id: 273638 cord_uid: mmlwh87u public health strategies to curb the spread of the coronavirus involve sheltering at home and social distancing are effective in reducing the transmission rate, but the unintended consequences of prolonged social isolation on mental health have not been investigated. we focused on hong kong for its very rapid and comprehensive response to the pandemic and strictly enacted social distancing protocols. thus, hong kong is a model case for the population-wide practice of effective social distancing and provides an opportunity to examine the impact of loneliness on mental health during the covid-19. we conducted an anonymous online survey of 432 residents in hong kong to examine psychological distress in the community. the results indicate a dire situation with respect to mental health. an astonishing 65.6% (95% c.i. = [60.6%, 70.4%]) of the respondents reported clinical levels of depression, anxiety, and/or stress. moreover, 22.5% (95% c.i. = [18.2%, 27.2%]) of the respondents were showing signs of psychosis risk. subjective feelings of loneliness, but not social network size, were associated with increased psychiatric symptoms. to mitigate the potential epidemic of mental illness in the near future, there is an urgent need to prepare clinicians, caregivers and stakeholders to focus on loneliness.  strict social distancing, implemented widely to curb the spread of covid-19, has the unintended consequences of prolonged social isolation and adverse impact on mental health.  we conducted an online survey to examine the impact of loneliness on mental health during covid-19 in hong kong, a model case for the population-wide practice of effective social distancing.  an astonishing 65.6% of the respondents reported clinical levels of depression, anxiety, and/or stress, and 22.5% were showing signs of psychosis risk.  loneliness, but not social network size, explained 12.0% to 29.2% of variance in these psychiatric symptoms.  to mitigate the potential epidemic of mental illness in the near future, there is an urgent need to prepare clinicians, caregivers and stakeholders to focus on loneliness. the corona virus disease 2019 , first started in china in december 2019, has spread across the globe within a few months and was declared a pandemic on march 11 th , 2020. many mental health professionals and scholars predict that the pandemic will have profound and long-lasting impact on mental health worldwide (holmes et al., 2020) . even prior to the current pandemic, mental illness was a global public health issue. according to the 2013 global burden of diseases study, psychological disorders were the fifth leading cause of disability worldwide . anxiety disorders and major depressive disorder each affected over 250 million people, and acute schizophrenia carried the highest disability weight of all diseases vos et al., 2015) . based on past observations of surges of psychiatric disorders and deaths by suicide following large-scale, life-threatening epidemics-for example, sars in 2003 (cheung et al., 2008 mak et al., 2009) , the 2014-2016 ebola epidemic (jalloh et al., 2018) , and the 1918-19 influenza pandemic (mamelund, 2010; wasserman, 1992) -and the unprecedented scale of the covid-19 pandemic, the extraordinary societal burden of mental illness is likely to grow further and rapidly in the near future. many expect a significant increase in the incidence of posttraumatic stress disorder (ptsd), depression, anxiety, substance use, suicide and other mental disorders, post-covid among the survivors, their caregivers, and healthcare workers (holmes et al., 2020) . indeed, preliminary results from china and italy confirm the high prevalence of ptsd, anxiety, depression, and perceived stress among the survivors of covid-19, and healthcare workers (bo et al., 2020; rossi et al., 2020) . the mental health impact of covid-19 will not be limited to those who are directly confronting (or have confronted) the disease. to contain the spread of the virus, nearly every country has implemented unprecedented levels and scales of quarantine, physical distancing, and even community lockdown. although effective in flattening the epidemic curve (matrajt and leung, 2020) , these public health strategies severely disrupt daily social life and limit interpersonal interactions with adverse consequences of social disconnection and loneliness, which play a central role in poor physical and mental health outcomes (cacioppo et al., 2015) , loneliness has been linked to premature death from stroke and cardiovascular diseases (valtorta et al., 2016) , altered expression of genes involved in inflammation and antiviral response (cole et al., 2015) , as well as increased depression, generalized anxiety disorder, panic disorder, suicide risk and psychosis (badcock et al., 2020; beutel et al., 2017) . with the prolonged social distancing related to covid-19, the general public will soon experience a surge in physical and mental illness. indeed, emerging data from china suggest increased incidence of mental illness among the general population following the covid-19 epidemic (gao et al., 2020; wang et al., 2020) . preliminary data also support the association between increased loneliness and greater depression (killgore et al., 2020) , although this relationship may be moderated by other psychological factors (shrira et al., 2020) . further studies are needed to confirm the role of loneliness in mental health during covid-19 with important factors likely impacting wellbeing controlled, and extend the investigation from depression and anxiety to other mental health concerns such as substance use and symptoms indicative of more severe disorders (e.g., psychosis). the present study examined wellbeing of the general public following prolonged social distancing during the covid-19 pandemic, and the role of loneliness and social network. we selected one of the first regions affected by covid-19 with strictly enforced quarantine and social distancing protocols since late january 2020-hong kong. hong kong is a special , 2020) . however, this early rapid response also means that the community has been living in prolonged social isolation since january 2020. we conducted an online survey of hong kong residents between march 31 st and may 30 th , 2020 to assess the physical and mental wellbeing after the city had implemented widespread social distancing for two months. we expected to observe high rates of common psychiatric symptoms (depression, anxiety, stress) as well as symptoms indicating emergence of severe mental illnesses (psychosis risk). furthermore, we expected that high levels of loneliness would be observed and would significantly explain health and mental health status, even after controlling for other key factors likely impacting wellbeing. respondents of this online survey were adults (age 18 or above), regardless of ethnic backgrounds and nationalities, currently residing in hong kong. a total of 555 unique visitors viewed the survey overview page in the period from march 31 st , 2020 to may 30th, 2020, out of which 461 were eligible for the survey by answering 18 or above for age and selecting "yes" or "part of the time" for the question of hong kong residence. of the eligible participants, 432 (93.7%) completed at least the demographics section and 347 (75.3%) completed the entire survey. only respondents completed at least the demographics section (n = 432) were included in the analyses below. these respondents on average completed 87.6% (median = 100%; sd = 27.5%) of the survey. the survey was available in two languages (traditional chinese and english) and was run on the qualtrics online platform (provo, ut). links to the survey were circulated on social media, local online forums or websites, and via words of mouth to reach the target population of hong kong residents. the survey was anonymous as no identifying information (e.g., name, date of birth, contact information, ip address) was asked or recorded. the median time respondents spent on the survey was 10 min 33s. this study received exempt determination from the university of michigan institutional review board (irb# hum00179454). the survey consisted of 145 questions assessing participants' demographics, general health, mental health, loneliness, and social network. the demographics and general health questions used in this survey (english version) can be found in supplementary information 1. items related to mental health, loneliness, and social network can be found in prior publications (detailed below). for mental health, the 21-item version of the depression anxiety stress scales (dass-21) (p. f. taouk moussa et al., 2001 ) was used to assess depression, anxiety, and stress levels. scores for depression, anxiety, and stress were calculated for each individual and classified into severity levels (normal, mild, moderate, severe, or extremely severe) according to the published norms (s. h. . the 16-item version of the prodromal questionnaire (pq-16) (ising et al., 2012 ) was used to screen for psychosis risk symptoms. for each individual, total score (i.e., number of items endorsed) and distress score (sum of distress related to endorsed items) were computed. a total score of 6 or higher was considered screened positive for psychosis risk syndrome (ising et al., 2012) . the ucla loneliness scale (russell, 1996) was used to assess the respondent's perceived loneliness. the social network index (sni) (cohen, 1997) was used to measure diversity (i.e., number of social roles) and size (number of people with whom the respondent has regular contact) of social network. respondents' demographics, general health, and mental health (dass-21 and pq-16 scores), loneliness (ucla total score), and social network (sni diversity and size scores) were examined with descriptive statistics. to understand the relationship of loneliness and social network to health and mental health, hierarchical regression analyses were conducted. this model comparison approach allows us to examine whether loneliness and/or social network can explain health and mental health above and beyond other demographic, psychological, and socio-political factors that likely have influence one's wellbeing. these include age, sex, exposure to domestic abuse, and worries about covid-19. given the current political context of hong kong where the residents had already been exposed to prolonged societal unrest and distress, we also considered the level of participation in the protest as a potentially influential factor. therefore, in step 1 of the hierarchical regression analyses, age, sex (two dummy coded variables: female, and no response to question of sex), frequency of domestic violence/abuse, level of concern about covid-19, and level of participation in the protests were entered as predictors into the reduced model. in step 2, stepwise method was used to add loneliness (ucla total score) and social network (sni diversity and size) measures as predictors into the full model. the dependent variables included: 1) self-report overall health; 2) numbers of days (over the past 30 days) in which physical health was not good; 3) numbers of days in which mental health was not good; 4) number of days in which poor physical or mental health affected usual activities; 5) number of days in which pain affected usual activities; 6) number of days in which the respondent felt worried, anxious, or tense; 7) dass-21 depression; 8) dass-21 anxiety; 9) dass-21 stress; 10) pq-16 total score; and 11) pq-16 distress score. since level of participation in the hong kong protests was not a significant predictor when included in any of the reduced or full models, and that nearly 20% of the respondents had a missing value on the item of (they chose not to answer the question), we removed this variable from the regression analyses to increase the sample size. the results of the regression analyses with or without this variable were virtually identical. we only report the results without this predictor variable below. because some respondents did not complete all the questions, the percentages reported below were calculated using the number of respondents completed the corresponding section as the denominator. summary of the 432 respondents who completed the demographics section is presented in comparatively, concern about the current covid-19 epidemic was much higher, with 360 (83.3%) of the 432 respondents expressing moderate or extreme concern (figure 1). 392 respondents completed the general health section. for self-perceived overall health, rated on a 1-5 scale (representing "excellent," "very good," "good," "fair," and "poor"), most respondents (71.4%) reported "good" or better (median = 3.0, mean = 2.9, sd = 0.97). about a third (34.9%) endorsed one or more of the following types of illnesses in the past 30 days: head cold or chest cold (14.0%); gastrointestinal illness with vomiting or diarrhea (16.3%); flu, pneumonia, or ear infections (9.7%); an ongoing or chronic medical condition (6.9%). only 3.8% were in mandatory or self-quarantine related to covid-19 (median duration = 14 days). none were in inpatient hospital care. few (9.9%) of the 389 respondents were cigarette smokers (mean = 0.68 packs/day, sd = 0.36) or alcohol drinkers (19.1%; mean = 3.6 drinks/week, sd = 4.2). however, among those who smoke or drink, many endorsed having been smoking (41.0%) or drinking (28.0%) more than usual in the past 30 days. the number of days in which various health-related problems occurred over the past 30 days are summarized in figure 2 . overall, the respondents reported more days affected by mental health issues than by physical health issues. 367 respondents completed the ucla loneliness scale. the mean score was 49.7 (median = 50.0; sd = 10.5), more than one standard deviation above the published norms obtained from samples of college students and nurses in north america (russell, 1996) . 356 respondents completed the social network index, reporting a mean number of social roles of 4.9 (median = 5.0, sd = 1.8, range = 1 -11). the mean number of people with whom the respondents have regular contact (i.e., at least once every 2 weeks) was 14.3 (median = 10.0, sd = 15.6, range = 0 -118). the model statistics of the hierarchical regression analyses are summarized in table 2; coefficients statistics are presented in supplementary information 2 (table s1 ). briefly, even after controlling for the effects of key variables that could impact health and mental health (age, sex, domestic violence exposure, and level of concern about covid-19), loneliness significantly explained variance (r 2 -change ranging from 1.3% to 29.2%) in all of the health and mental health measures (except the number of days in which usual activities were affected by pain). this amount was even higher for models using scores of validated scales of psychiatric symptoms (i.e., dass and pq16) as the dependent variable, with r 2 -change ranging from 12.3% to 29.2%. social network diversity and size did not significantly explain any of the health and mental health measures. the findings of this survey paint a very disconcerting picture of the mental health status among people in hong kong during the covid-19 pandemic. although many respondents reported overall good physical health and few days in the past month in which they were affected by physical health or pain issues, they suffered mental health issues frequently in that they experienced poor mental health or feeling worried, anxious or tense, on average, in more than one-third of the time over the past month. their responses to validated scales of psychiatric symptoms suggest that almost two-thirds (65.6%) reported clinical levels of depression, anxiety, and/or stress. population-wide incidence and prevalence of psychiatric disorders prior to covid-19 have been tracked by the large community-based studies of mental health lee et al., 2011) ; weighted prevalence was estimated at 13.3 % for any past-week for any psychiatric condition, with mixed anxiety and depressive disorder being the most frequent diagnoses. therefore, our results from the current survey indicate a significant increase in the risk for mental illness in the general population. yet more concerning is the high rate (22.5%) of elevated risk for a psychotic disorder observed in this study. previous studies using the same measure found only 4.0% of help-seeking young people in north america screened positive for psychosis-risk (ising et al., 2012) . a prior population-based household survey for mental disorders estimated a lifetime prevalence of all psychotic disorders to be approximately 2.5% among the chinese adult population in hong kong (chang et al., 2017) ; this estimate is similar to the prevalence reported globally, suggesting that the elevated psychosis risk found in this study was not due to a higher "baseline" psychosis risk among hong kong people. this is a population with low rates of smoking (9.9%) or drinking alcohol on a regularly basis (19.1%). while the smoking rate in this sample was similar to that reported in the 2015 census (10.5%) (census and statistics department, 2018), the drinking rate was much higher than the 11.1% reported in the population health survey 2014/15 (centre for health protection, 2017). among those who smoke or drink alcohol regularly, many reported having been smoking (41%) or drinking (28%) more heavily in the past month. taken together, these findings indicate that the societal impact of the covid-19 in hong kong extends beyond the illness itself and well into the future, with sharp increases in the risk for depression, anxiety, stress, psychosis, and substance use. in addition to psychiatric symptoms, level of loneliness was very high in this hong kong sample: it was one standard deviation elevated compared with samples of similar education attainment (college students and nurses) in north america (russell, 1996) . furthermore, loneliness significantly explained physical and mental health across measures, even after accounting for the effects of other important variables (age, sex, domestic abuse/violence frequency, and level of concern for covid-19). the only health measure not significantly explained by loneliness was the number of days affected by pain, likely due to the very low frequency of pain in this sample. whilst the prevalence of psychological distress found in this sample during the pandemic is daunting, our finding that loneliness is playing a central role may give us a handle to address this public health emergency at a societal level. to mitigate the potential epidemic of mental illness in the near future, there is an urgent need to prepare clinicians, caregivers and stakeholders to focus on loneliness. reducing loneliness could result in reduction of mental illness across all diagnostic categories. our finding that social network size (number of social roles, and number of people in the social network) failed to explain any of the health and mental health measures suggests that it is the quality rather than quantity of interpersonal relationships that matters. therefore, interventions that can strengthen social connectedness (e.g., training in communication and social skills, consistent group activities) may exert larger impact than focusing only on increasing the amount of social encounters. furthermore, interventions need to be implemented at a broad societal level rather than for a small fraction of the population. creative solutions, including those leveraging technology, are likely needed to help achieve this goal. it is important to remember that individuals with preexisting psychiatric conditions or those who were already marginalized in society are likely to be impacted even more by the social distancing protocols introduced to reduce the transmission rate of the virus and economic aftermath of the pandemic (tsai and wilson, 2020; yao et al., 2020) , and we must deploy more resources and social capital to address the mental health needs of people disproportionately affected by the pandemic. ongoing pro-democracy movement (reuters, 2020) , which has been assailed by an unprecedented level of violent crackdown (amnesty international, 2019; time, 2019) and persecution by the authorities (pang, 2020) . this sociopolitical context must be considered when interpreting the findings of this study. the city was already embattled with a mental health crisis before the pandemic. a study conducted in late 2019, just before the covid-19 epidemic in hong kong, showed high rates of probable posttraumatic stress (12.8%) and depression (11.2%) among the residents, especially the younger (age 18-35) cohort who show higher level of support for the protests (ni et al., 2020) . the pandemic further deteriorated people's mental health, not only through prolonged social distancing, but also economic decline (lam, 2020a) , surge of unemployment rate (lam, 2020b) , and public mistrust of the government (marlow and hong, 2020; radio television hong kong, 2020) . therefore, the alarming covid-19 related mental health status found in this study was likely amplified by ongoing societal problems, some of which are in common with other countries and some are unique to hong kong. this study has several limitations. the sample was relatively young and highly educated, unlikely to be fully representative of the hong kong population. this was a cross-sectional study and lacked longitudinal data to track changes in mental health over time during the pandemic. however, the rates of psychiatric symptoms founded in this study were higher than the estimates reported in a study of a representative sample conducted in december 2019 (ni et al., 2020) , just before the first confirmed case of covid-19 was reported. this provides some preliminary evidence for the adverse consequences of covid-19 on mental health across broad domains including psychosis. additionally, although level of participation in the hong kong protests was not a significant predictor of mental health status in the regression analyses, it should be noted that a non-trivial proportion of the respondents (~20%) chose not to answer this question. it is possible that respondents who participated frequently in the protests were more likely to skip this question because they were worried about political or legal repercussions. however, it is also possible that those who never or rarely participated in the protests tended to skip this question because of social desirability (the protests are widely supported by people in hong kong). it is unclear whether the data of this question were missing at random or not. in so far as we could test from the available data, we could only conclude that level of participation in the hong kong protests did not predict health/mental health status. this may be because the political crisis and social unrest affected everyone negatively regardless of one's political orientation. obviously, this result applies only to this sample at this given point in time. the political situation has significantly worsened since our survey, so it is possible that the impact of participation in political protests has changed as well. finally, the survey data were collected mostly in april 2020; it is unknown how mental health outcome would be impacted by the lifting of social distancing protocols worldwide, potentially followed by a second-or even third-wave of the pandemic. close monitoring of the mental health impact of this pandemic is warranted. to conclude, this study investigated the mental health status of ordinary citizens and the impact of loneliness in a city that was one of the first regions that practiced population-wide social distancing during the covid-19 pandemic. the results indicate a dire situation with respect to mental health, with highly elevated rates of significant psychiatric symptoms including depression, anxiety, stress, and signs of psychosis risk. subjective feelings of loneliness, but not social network size, significantly explained these increased psychiatric symptoms above and beyond other demographic factors. these findings together suggest that there will likely be an epidemic of mental illness in the near future, and preparing clinicians, caregivers and stakeholders to focus on alleviating loneliness would be one effective way to mitigate this impending public health crisis. the authors thank the respondents for donating their valuable time to complete this survey. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. note. all predictive models included 6 predictive variables: age, sex (two dummy coded variables: female, and no response to the question of sex), frequency of domestic abuse/violence, level of concern about covid-19, and ucla loneliness score. change statistics were relative to the reduced model, which contained only 5 predictive variables (i.e., all variables except ucla loneliness score). physical health was not good: mean = 4.8 days (sd = 6.9). b) mental health was not good: mean = 11.6 days (sd = 10.0); c) usual activities were affected due to health problems: mean = 3.9 days (sd = 7.2); d) usual activities were affected due to pain: mean = 1.9 (sd = 4.5); and e) feeling worried, anxious, or tense: mean = 14.1 days (sd = 10.8). coronavirus disease (covid-19) in hk [www document multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science. the lancet psychiatry the validity of the 16-item version of the prodromal questionnaire (pq-16) to screen for ultra high risk of developing psychosis in the general help-seeking population impact of ebola experiences and risk perceptions on mental health in sierra leone letter to the editor. loneliness : a signature mental health concern in the era of covid-19 pandemic and politics push hong kong's economy into record slump hong kong's unemployment rate rises to highest since prevalence, psychosocial correlates and service utilization of depressive and anxiety disorders in hong kong: the hong kong mental morbidity survey (hkmms) a community study of generalized anxiety disorder with vs. without health anxiety in hong kong the structure of negative emotional states: comparison of the depression anxiety stress scales (dass) with the beck depression and anxiety inventories manual for the depression anxiety & stress scales long-term psychiatric morbidities among sars survivors the impact of influenza on mental health in norway hong kong police arrest protesters for violating social distancing guidelines evaluating the effectiveness of social distancing interventions to delay or flatten the epidemic curve of coronavirus disease depression and post-traumatic stress during major social unrest in hong kong: a 10-year prospective cohort study hong kong police detain veteran democracy activists in raids hundreds of medical workers walk off in protest timeline: key dates in hong kong's anti-government protests [www document mental health outcomes among frontline and second-line health care workers during the coronavirus disease 2019 (covid-19) pandemic in italy ucla loneliness scale (version 3): reliability,validity, and factor structure disability weights for the global burden of disease 2013 study covid-19 related loneliness and psychiatric symptoms among older adults: the buffering role of subjective age psychometric properties of a chinese version of the 21-item depression anxiety stress scales (dass21) covid-19: a potential public health problem for homeless populations loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and metaanalysis of longitudinal observational studies immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china the impact of epidemic, war, prohibition and media on suicide: united states, 1910-1920 patients with mental health disorders in the covid-19 epidemic key: cord-318311-aakpbbvl authors: du, na; ouyang, yingjie; chen, yong title: the experience of prevention measures taken by the psychiatric hospital during the emergence of asymptomatic patients with covid-19 date: 2020-05-30 journal: psychiatry res doi: 10.1016/j.psychres.2020.113109 sha: doc_id: 318311 cord_uid: aakpbbvl nan the outbreak of the covid-19 pandemic has lasted for five months. on april 8, 2020, wuhan, china lifted the lockdown. a large number of people stranded in wuhan due to the lockdown gradually returned to their hometowns. despite china's staged success in preventing and containing the epidemic, the emergence of asymptomatic infections has kept the government vigilant. while faced with such a severe pandemic, all countries should learn the experiences in containment from each other and adapt to their circumstances. especially for medical institutions, how to implement effective epidemic containment measures in the first place becomes the most important thing to prevent the spread of the epidemic. due to the high infectivity of the covid-19, without proper countermeasures, any input of infected patients would contaminate the entire ward. therefore, most psychiatric hospitals in china like wuhan mental health center (wmhc) adopted the closed management mode of inpatients (visit prohibited) during this time. despite this, unfortunately, on february 8, china news weekly reported that nosocomial infection had occurred in wmhc [1] . thus, how to do an excellent job in epidemic prevention in psychiatric hospitals became a big challenge. chengdu, sichuan province, as a major city for exporting labor to wuhan, was facing a great risk of infection imports. the fourth people's hospital of chengdu, also known as chengdu mental health center, is a psychiatric specialty hospital that can accommodate 1,400 patients. after the outbreak, our hospital quickly adopted a series of countermeasures, including the establishment of fever clinics to screen patients for suspected covid-19 infections, prohibiting family visits in closed inpatient wards, and extending the closed management mode to all departments. it is worth mentioning that the hospital temporarily established a transitional ward to treat patients who met the mandatory admission criteria during the outbreak. these patients needed to be quarantined for 14 days until they were confirmed to be excluded from the infection of covid-19 and then transferred to other general wards. other specific measures have been reported in detail in a relevant journal and will not be elaborated here [2] . although china's domestic situation was under control, a nosocomial infection in harbin occurred half a month ago once again sounded the alarm of epidemic prevention. during the hospitalization of a patient with respiratory symptoms in harbin, more than 20 people were directly and indirectly infected with covid-19. through the continuous tracing of the confirmed cases, as of april 21, 2020, the chain of transmission has caused 75 people to be infected with covid-19, of which 52 were confirmed patients and 23 were asymptomatic infections [3] . according to the current understanding of the symptoms of the covid-19, most patients have fever symptoms [4] , but there are also a large number of asymptomatic infections, which makes the most basic and most commonly used screening method, that is the body temperature test be no longer effective. referring to the nosocomial infection incident in harbin, our hospital has updated a new screening procedure for all newly admitted patients to prevent the import of infections. the procedure is as follows: 1. all newly admitted patients must undergo nucleic acid testing, and the specific screening process is as follows: a. patients with fever, epidemiological history, or respiratory symptoms within 14 days must enter the fever clinic to complete blood routine examination, crp, chest ct, and nucleic acid sampling. if the blood routine and chest ct results are not abnormal, and the suspected infection of covid-19 is excluded, the patient can be admitted to the hospital and isolated in a single room. during isolation, samples shall be taken as soon as possible for the nucleic acid test. only when the test result is negative can the patient be transferred to the general ward. otherwise, if the patient's chest ct and blood routine suggest viral infection, the patient must wait for the nucleic acid test result in the fever clinic. only when the nucleic acid result is negative can the patient be admitted to the hospital. b. patients with no fever, epidemiological history, or respiratory symptoms within 14 days need to complete the blood routine examination, crp, and chest ct in the outpatient or emergency department. if there is no abnormality, the patient can be admitted to the hospital and isolated in a single room for the nucleic acid test. the patient could not be transferred to the standard ward until the test result shows negative. if the chest ct examination indicates signs of infection, the doctor should refer the patient to the fever clinic and do the nucleic acid test. only when the nucleic acid result is negative can the patient be admitted to the hospital. 2. patients in the hospital who have fever or respiratory symptoms must undergo nucleic acid testing. 3. each newly admitted patient needs to enter the isolation ward from the designated channel to avoid contact with other inpatients. the attending physician needs to collect the epidemiological history in the isolation ward alone with first-class protection. 4. once there is a suspected covid-19 infected patient or a confirmed case in the ward, that ward needs to be closed. all personnel who have contact with the patient must not leave the ward, even after work. other staff who have not contacted the patient shall not enter that ward until the patient can be excluded from infection, and staff can then pass the ward. 5. before entering the inpatient ward, all nursing stuff are required to undergo the nucleic acid test, provide health certificates, and obtain a nursing card issued by the hospital. in principle, all nurses cannot be replaced during hospitalization. if the patient needs to change nurses or the nurse needs to leave the inpatient ward, the nucleic acid test should be conducted again before re-entering. since our hospital constantly adjusted the countermeasures according to the epidemic situation and implemented dynamic management and evaluation, since the outbreak, the number of covid-19 infections diagnosed in our hospital is 0, and there were no other related nosocomial infections occurred. therefore, we would like to share our experience of the epidemic prevention and control implemented in our hospital and the management experience during the epidemic, hoping to provide a reference for other hospitals to overcome the difficult situation. the risk and prevention of novel coronavirus pneumonia infections among inpatients in psychiatric hospitals covid-19 prevention and control strategies for psychiatric hospitals clinical features of patients infected with 2019 novel coronavirus in wuhan we sincerely thank all the healthcare workers in our hospital for their assistance in this study. on behalf of all authors, the corresponding author states that there is no conflict of interest. key: cord-270046-bxtez39p authors: bourion-bédès, stéphanie; tarquinio, cyril; batt, martine; tarquinio, pascale; lebreuilly, romain; sorsana, christine; legrand, karine; rousseau, hélène; baumann, cédric title: psychological impact of the covid-19 outbreak on students in a french region severely affected by the disease: results of the pims-cov 19 study date: 2020-11-05 journal: psychiatry res doi: 10.1016/j.psychres.2020.113559 sha: doc_id: 270046 cord_uid: bxtez39p the covid-19 has sent billions of students worldwide into lockdown. the study aimed to assess the prevalence of anxiety and identify the factors associated with anxiety among french students during lockdown.a cross-sectional study was conducted to collect sociodemographic data, living and learning conditions, anxiety symptoms and social support. among 3936 students, 15.2%, experienced moderate anxiety and 9.8%, severe anxiety.female gender (or=2.2, 95% ci: 1.8-2.7) and having relatives or acquaintances from their housing hospitalized for covid-19 (or=3.3, 95% ci: 1.4-7.9) were the main risk factors for anxiety. tensions at home (or=1.8, 95% ci: 1.5-2.1), difficulties isolating (or=1.4, 95% ci: 1.1-1.6), noises inside (or=1.6, 95% ci: 1.3-1.9) or outside the housing (or=1.5, 95% ci: 1.3-1.8), no direct outdoor access (or=1.6, 95% ci: 1.3-2.0), delay in final examination (or=1.6, 95% ci: 1.3-2.1), reduced time for learning (or=1.3, 95% ci: 1.1-1.6), increased tobacco consumption (or=1.9, 95% ci: 1.4-2.6), ineffectiveness of using media entertainment (or=2.2, 95% ci: 1.1-4.4) and reading (or=1.9, 95% ci: 1.3-2.7) to calm down, were identified as risk factors. family (or=0.85, 95% ci: 0.8-0.91) and friend (or=0.88, 95% ci: 0.82-0.94) support were protective factors. this suggests the need to focus on students during epidemics, especially those living with someone hospitalized with covid-19. coronavirus disease 2019 , which was first identified in wuhan city in east china in december 2019 (zhu et al., 2019) , has spread at an alarming rate and become a major challenging global public health problem (phelan et al., 2020) . in response to this pandemic situation, the world health organization (who) declared a public health emergency of international concern on january 30, 2020 (who, 2020) . although the mortality rate of covid-19 outside china was initially rather low (kang, 2020) , leading to the expectation that the effect of the disease on the health of individuals in other countries would be minor, this view rapidly changed. in france, the most recent reports of laboratory-confirmed covid-19 cases and deaths are as follows: through july 15, 2020, a total of 174 674 patients were diagnosed with confirmed cases, of whom 30 152 died due to covid-19 and 79 244 recovered and were discharged from hospitals. since march 15, 2020, some unprecedented measures have been adopted in france with the intention of controlling covid-19 transmission and avoiding contact with others. as in many countries, officials with the french government have announced the closure of schools, colleges, universities and other educational institutions to prevent the rapid spread of covid-19 by disrupting important chains of transmission (sahu, 2020) . according to monitoring by the united nations educational, scientific and cultural organization (unesco), the closure of educational institutions impacted over 87% of the student population worldwide (de oliveira et al., 2020) . students, as well as universities, became uncertain about how online teaching would be delivered, such as the procedures for assessments, projects and semester-end final examinations (sahu, 2020) . this situation has created a sense of uncertainty, stress and anxiety that might lead to unfavourable outcomes regarding the psychological health of students (al-rabiaah et al., 2020) . several other measures were also implemented, including travel restrictions, social distancing, and closures of restaurants, movie theatres, gyms, museums, and other places involving potential gatherings, leading students to protect themselves from any person-to-person contact and to live in self-isolation until the situation became normal. based on a number of recent studies, students have been identified as a vulnerable group that experiences significant levels of stress-related mental health concerns, including anxiety and depression (regehr et al., 2013) . thus, before the pandemic started, one in five college students worldwide had experienced one or more diagnosable mental disorders (auerbach et al., 2016; zhai et al., 2020) . according to previous research, individuals experience negative emotional responses, such as anxiety and depression symptoms, during an outbreak (zhou et al., 2020) , and stressful events and public health emergencies such as the covid-19 outbreak are potent adverse environmental factors that may exert greater psychological effects on students that are expressed as anxiety, fear and worry [mei et al., 2011; fiorillo et al., 2020) . a recent study among chinese college students revealed that 24.9% experienced anxiety because of this covid-19 outbreak. overall, living in urban areas, living with parents and having a steady family income were identified as protective factors against anxiety in college students, while having a relative or an acquaintance infected with covid-19 was an independent risk factor for experienced anxiety (cao et al., 2020) . similarly, a study reported increased scores for anxiety, depression, and suicidal thoughts, worsened quality of life and decreased quality of sleep among greek students during the lockdown (kaparounaki et al., 2020) . based on this recent literature on the psychological impacts of the epidemic among students and because the grand est region was one of the three french regions that was most severely affected by the covid-19 outbreak, the students from this area may be at particular risk of developing severe mental health issues. thus, to evaluate their mental health and to understand student needs in order to develop interventions, this study aimed to assess the prevalence rate of anxiety and determine which sociodemographic, living conditions and health status characteristics could predict anxiety among french students during the lockdown due to the covid-19 outbreak. this study is a cross-sectional analysis of data from the feelings and psychological impact of the covid-19 epidemic among students in the grand est area (pims-cov19) study, an observational study that was conducted through an online survey. the online questionnaire was accessible from may 7 to may 17, 2020 and each participant had the opportunity to complete it only once. twenty minutes were required to complete the survey. a sample of students was recruited from the university of lorraine and the sciences po college located in nancy, lorraine, grand est region, france. the grand est region was an area that ranked among the french regions that was most substantially affected by covid-19 in terms of the incidence of covid-19 cases, with 19.6 cases per 100 000 inhabitants during the period of the survey. all students received detailed information regarding the purpose of the study and provided online informed consent to participate in the study. the survey was completed anonymously to ensure the confidentiality and reliability of the data. all procedures were conducted in accordance with the principles of the declaration of helsinki. when the study was launched, it targeted the entire student population in lorraine, i.e. more than 50 000 students. we had estimated that 5-10% of the students would respond to the survey, i.e., between 2 500 and 5 000 students. no prior sample size calculation was performed. the survey consisted of three sections: questions regarding sociodemographic data and living conditions during the lockdown, concerns regarding the threat to health posed by covid-19 and control measures, and health status measures assessed with self-administered questionnaires. all data were obtained at the time of the online survey. the 7-item generalized anxiety disorder scale (gad-7) was used to assess anxiety symptoms. it includes seven items based on seven core symptoms, and the participants were asked how often they were bothered by each symptom during the last two weeks (spitzer et al., 2006) . each item was rated on a 4-point likert scale ranging from 0 "not at all" to 3 "nearly every day" such that the total score ranged from 0 to 21. it is currently the most widely used anxiety measure, both in clinical practice and research (toussaint et al., 2020) . the scores for symptom severity were 5-9 for mild anxiety, 10-14 for moderate anxiety, and 15-21 for severe anxiety (spitzer et al., 2006) . the french version of the gad-7 was used, as it has yielded valid clinical assessments of anxiety. a good internal consistency with cronbach's alpha coefficient of 0.898 was previously established, and good external validity has been confirmed (micoulaud-franchi et al., 2016) . the scale has been used in many studies to assess anxiety symptoms in students (musiat et al., 2014; kayotaki et al., 2019; cao et al., 2020) . the 12-item multidimensional scale of perceived social support (mspss) was used to assess social support from three sources: family, friends and significant others (zimet et al., 1988) . the students were asked to indicate their level of agreement with each item on a 7-point likert scale ranging from 1 "very strongly disagree" to 7 "very strongly agree." the total score of each dimension and the total scored range from 1 to 7, with higher scores indicating higher perceived social support. the french version of the mspss has proven to have good psychometric properties. good internal reliability and reproducibility were previously established (denis et al., 2015) . the original version yields valid clinical assessments of perceived social support among students (dahlem et al., 1991) . the students self-reported their demographic characteristics, including age, gender, living arrangements, home location and academic demographic information, such as academic programme and scholarship status. they were also asked about their living and learning conditions, changes in their consumption of psychoactive substances, their preventive behaviours regarding covid-19 and the presence of a relative or acquaintance infected with covid-19. continuous variables were described by the mean and standard deviation or the median, as appropriate, and categorical variables by percentages. a logistic regression analysis was performed to determine the variables associated with moderate to severe anxiety. the probability modelled was a gad-7 score higher than 10 (spitzer et al., 2006) . sociodemographic characteristics, learning and teaching conditions, the influence of living conditions, concerns regarding the health threat posed by covid-19 and self-perceived social support scores were investigated. relevant factors were identified as factors that were associated in the bivariate analysis at the 10% threshold. the suitability of the full model was evaluated and compared with a model to which a stepwise selection of candidate variables was applied using a significance level entry of 0.1 and a significance level stay of 0.05. the goodness of fit was assessed by calculting the model determination coefficient (r2), and the hosmer and lemeshow test allowed the comparison and selection of the best multivariable model. only significant factors at the 5% threshold in the level models were retained for multivariable analyses. analyses were performed using sas 9.4 software (sas inst., cary, nc, usa). as shown in table 1 , 3 936 students were recruited in the pims-cov19 study, more than twothirds of whom were women (70.6%). the mean and median ages were 21.7 (sd=4) and 21 years old, respectively. among the sample, 67.5% of students lived with their parents, while 18.7% lived alone and 7.7% lived in colocation during the lockdown. more than half lived (59.3%) in urban areas, and 60.1% had a domestic garden that provided the opportunity for students to have immediate outside contact. one-quarter of the students (28.3%) experienced conflicts within the housing where they were confined, and 25.1% found it difficult to isolate themselves in the dwelling. the largest group of participants were students of the faculties of sciences, including sport sciences, science and technology and medical sciences (57.9%), followed by students in the faculties of law, economy and management (14.1%). due to disruptions in the academic routine, one-third of the students (36.2%) received total online teaching. the time working at home did not change for 29.2% of the students. for 13.4% of the students, the pandemic had a serious impact due to the postponement of a final examination. of the 3 936 students, 40.7% received a financial aid programme as scholarship students and 14.4% had their student part-time job end during the lockdown, in addition to their interrupted studies. one-third of the participants (34.5%) had a relative or acquaintance who was infected with covid-19, and 4.3% had someone in their housing infected with covid-19. as shown in table 2 , seventeen percent of the students (17.7%) reported consuming drinks two or more times per week before the lockdown. under the lockdown, thirteen percent (13.7%) reported consuming more alcohol and 35% reported consuming less alcohol. tobacco use increased for 7.2% of the students. more than three-quarters of the students (84.7%) adopted daily preventive behaviours regarding covid-19 in their housing location. as shown in table 3 , media entertainment was largely successfully used by students rather than physical exercise and reading as a means to relieve their distress and address their concerns regarding the negative conditions they were experiencing. the gad-7 results are presented in table 4 . the mean gad-7 score was 6.7 (sd=5.0). the rate of mild anxiety was 36%, and the rates of moderate and severe anxiety were 15.2% and 9.8%, respectively. the proportion of all of the students with mild-to-severe anxiety symptoms was 61%. the mean mspss total score was 5.5 (sd=1.1). the mean scores for support from family, friends and significant others were 5.2 (sd=1.5), 5.5 (sd=1.3) and 5.7 (sd=1.3), respectively. the results of bivariate and multivariable analyses are reported in table 5 . among the sociodemographic variables, female gender was a risk factor for anxiety symptoms (or=2.2, 95% ci: 1.8-2.7, p<0.0001). regarding academic programmes, being engaged in arts, humanities, and languages was a risk factor for anxiety (or=1.8, 95% ci: 1.4-2.4, p=0.0004). among the learning conditions, the delay of final examinations (or=1.6, 95% ci: 1.3-2.1, p<0.0001) and the reduced time for learning due to academic disruption (or=1.3, 95% ci: 1.1-1.6, p=0.031) were found to be risk factors for anxiety symptoms. in terms of living conditions during the lockdown, the results indicated that many factors were associated with anxiety during the covid-19 crisis: tensions and conflicts with family or occupants of the dwelling (or=1.8, 95% ci: 1.5-2.1, p<0.0001), difficulties in being able to isolate in the housing location (or=1.4, 95% ci: 1.1-1.6, p=0.0015), indoor noise in the housing location (or=1.6, 95% ci: 1.3-1.9, p<0.0001), noise outside the housing location (or=1.5, 95% ci: 1.3-1.8, p<0.0001) and no private direct access to outside through a garden, a terrace or a balcony (or=1.6, 95% ci: 1.3-2.0, p=0.0006). in terms of student behaviours, increased tobacco consumption was a risk factor for anxiety symptoms (or=1.9 95% ci: 1.4-2.6, p=0.0002). the self-perceived ineffectiveness of both media entertainment (or=2.2, 95% ci: 1.1-4.4, p=0.0006) and reading (or=1.9, 95% ci: 1.3-2.7, p<0.0001) to calm down were risk factors for anxiety. however, when reading was perceived as an effective means to calm down, it was a protective factor against anxiety (or=0.7, 95% ci: 0.6-0.97, p<0.0001). regarding snacking, the greater the extent snacking was perceived as an effective means to calm down, the higher the risk of anxiety symptoms (or=1.9, 95% ci 1.4-2.5, p=0.0002). family support (or=0.85, 95% ci: 0.80-0.90, p<0.0001) and friend support (or=0.88, 95% ci: 0.82-0.94, p<0.0001) were protective factors against anxiety symptoms. having someone in their housing affected by covid-19 was the highest risk factor for anxiety symptoms (or=3.3, 95% ci: 1.4-7.9, p=0.0006). important to the primary aim of this study was the finding that 61% of students in the sample experienced anxiety during the lockdown due to the covid-19 outbreak. this result is well above the value of 24.9% of chinese students from changzhi medical college who were afflicted with experienced anxiety (cao et al., 2020) and the 22.1% of medical students enrolled at tongji medical college who experienced anxiety during the covid-19 outbreak quarantine period (liu j et al., 2020) . based on our results, the psychological impact of the disease on the student population in a french area that was particularly affected by covid-19 is significant. this high prevalence might be explained by an online assessment during a period when the period of isolation had lasted for more than one month and was prolonged by the government. in addition to the high infectivity and french mortality rate of covid-19 relayed daily by the french media, the consequences of the prolongation of isolation in their homes might induce more anxiety among the students. this result highlights the students' perceptions of the serious threat at the peak phase of the covid-19 pandemic and seriously contrasts with the low anxiety levels in the french population during the a/h1n1 influenza pandemic (schwarzinger et al., 2010; bults et al., 2015) . the results of this study also indicated that several characteristics were associated with students' moderate to severe anxiety. among the sociodemographic characteristics, female gender was associated with a higher level of anxiety during the covid-19 outbreak, which differed from a previous study indicating that male and female students experienced similar levels of stress and negative emotions as a result of the epidemic (cao et al., 2020) . however, our result was consistent with a previous study conducted during the epidemic reporting that female gender was the highest risk factor for anxiety among chinese high school students (zhou et al., 2020) . the delay of a final examination and being in the arts, humanities and languages academic programmes were also significant factors contributing to students' experienced anxiety during the covid-19 crisis. this result might be explained by the difficulties associated with teaching some courses, such as fine arts, art, and music, online, as previously suggested (sahu, 2020) , and supports the need for a method by which students receive regular information about competitions, exams or assessment deadlines through university intranets during the outbreak. furthermore, several characteristics of the students' living conditions were associated with student anxiety. in contrast to previous findings, students living in rural areas were not more likely to be anxious (zhou et al., 2020; cao et al., 2020) , but students without private outside access (terrace, garden, or balcony) were more likely to be anxious. nevertheless, the lack of private direct outside access through a terrace or a balcony might be explained by the economic resources of the students. although many of them made a lifestyle change during the lockdown by returning to their home with their parents, living with parents was not found to be a significant factor contributing to reduced anxiety, as previously reported (cao et al., 2020) . regardless of the place of residence, conflicts at home, difficulties isolating themselves and noisy environments added to students' anxiety. similarly, students using self-perceived inefficient strategies to calm down were most likely to be anxious. these environmental factors highlighted by this study support the need to develop behavioural strategies that focus on relaxation exercises and activity scheduling (homebased exercises) to counteract anxiety in the home environment . consistent with previous findings, social support reduced psychological pressure and appeared to be a protective factor against anxiety, as anxiety disorders are known to be more likely to occur in the absence of interpersonal communication (jin et al., 2014; chen et al., 2020) . increased cigarette smoking was associated with students' anxiety symptoms. the factors underlying this association are still being discussed with two types of hypotheses. one is that anxious individuals are at an elevated risk of smoking due to the presumed calming effects of smoking (kassel et al., 1997) . another is that cigarette smoking contributes to the development of anxiety disorders due to factors such as the presumed anxiogenic effects of nicotine (pohl et al., 1992) . however, the results of a prospective study have shown that cigarette smoking might increase the risk of anxiety disorders during late adolescence and early adulthood (johnson et al., 2000) . as expected, because it has been noted as an important variable in the literature , having relatives or acquaintances at home who are infected with covid-19 and subsequently hospitalized were clearly the main risk factors for increasing the anxiety of the students, which might be related to the high contagiousness of the disease (who, 2020). based on this result, effective and robust support is necessary for the family or indivdiduals in a close environment with an infected person during public health emergencies. it contributes to evidence that social support and psychological interventions are needed to decrease the anxiety of students when a relative is infected and hospitalized with covid-19. the results from this study should be interpreted in light of a number of strengths and limitations. first, the representativeness of the sample is limited, as it is a sample of voluntary participants, which may have led to an over-evaluation of anxiety. second, the greater proportion of female students may have limited the representativeness. third, the students were recruited from one of the french areas that was the most substantially affected by thereby limiting the generalizability of these results to all students. fourth, the data were collected using electronic self-report questionnaires, which may have excluded persons without internet access and which, although anonymous, may introduce bias-specific to socially desirable responses. finally, despite the large number of determinants included in the analyses, the multivariate model explained 25% of the explained variance; thus, other factors, such as anxiety due to media coverage and daily accurate information regarding the infection rates and number of deaths, were not accounted for by our study and should be included in future studies. however, this study provides invaluable information on the anxiety of students in a french area particularly affected by covid-19. our results bring attention to the interesting findings that health initiatives for students should include improvements in learning and living environments. simply developing resources to facilitate online guidance and lectures to offer strategies for managing anxiety and building a campus environment that offers access to a private outside space for the students are essential, as these actions might result in mental health benefits. based on the findings of the present study, more than half of the students in a french area particularly affected by covid-19 experienced anxiety during the lockdown due to the covid-19 outbreak. although the virus continues to circulate, the epidemic is under control in france. however, it is still spreading elsewhere, and recommendations are needed in preparation for a possible second wave. the female gender, having a relative or an acquaintance at home infected with covid-19 and some living conditions were the main factors associated with higher levels of anxiety. several key messages should be highlighted based on these findings. first, the government should focus more on psychological health among students while combating covid-19. then, the results provide some novel information that identifies high-risk groups among students and promotes specific and effective interventions aimed at this particular group, thus providing potential psychological benefits. all students received detailed information describing the purpose of the study and provided online informed consent to participate in the study. the survey was anonymously to ensure the confidentiality and reliability of the data. all procedures were conducted in accordance with the principles of the declaration of helsinki. abbreviations: or, odds ratio: the probability of gad-7 score >7; or<1, decreased frequency of gad-7 score > 7; or>1, increased frequency of gad-7 score > 7; sd, standard deviation; mspss, multidimensional scale of perceived social support abbreviations: or, odds ratio: the probability of gad-7 score >7; or<1, decreased frequency of gad-7 score > 7; or>1, increased frequency of gad-7 score > 7; sd, standard deviation; mspss, multidimensional scale of perceived social support ¥ for these variables, the p-value is for global comparison of each modality of 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targeted prevention of common mental health disorders in university students: randomised controlled trial of a transdiagnostic trait-focused web-based intervention examining the effectiveness of a web-based intervention for symptoms of depression and anxiety in college students: study protocol of a randomised controlled trial the multidimensional scale of perceived social support evaluation of the french version of the multidimensional scale of perceived social support during the postpartum period the multidimensional scale of perceived social support: a confirmation study online mental health survey in a medical college in china during the covid-19 outbreak. front psychiatry low acceptability of a/h1n1 pandemic vaccination in french adult population: did public health policy fuel public dissonance? perceptions and behavioral responses of the general public during the 2009 influenza a (h1n1) pandemic: a systematic review immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china prevalence and risk factors of anxiety status among students aged 13-26 years mental health care for medical staff in china during the covid-19 outbreak attentional mediation of cigarette smoking's effect on anxiety smoking in patients with panic disorder association between cigarette smoking and anxiety disorders during adolescence and early adulthood the impact of covid-19 on anxiety in chinese university students the authors declare that they have no competing interests. key: cord-355944-8q4s1kf9 authors: dixit, ayushi; marthoenis, marthoenis; arafat, s.m. yasir; sharma, pawan; kar, sujita kumar title: binge watching behavior during covid 19 pandemic: a cross-sectional, cross-national online survey date: 2020-05-13 journal: psychiatry res doi: 10.1016/j.psychres.2020.113089 sha: doc_id: 355944 cord_uid: 8q4s1kf9 nan to the editor, during the covid-19 lockdown phase, people experience anxiety and emotional break down (1) . as people face days of isolation at home, this creates an ideal condition to engage in online activities and watching television. as recreation sources are limited at home settings and internet/television are easily accessible, readily available and of course affordable; it may result in binge-watching. people with binge-watching behavior often watch multiple episodes in a single go (2) . considering this fact, the tele-industry is spending on making web-series that compel people for binge-watching and to promote this behavior often all the episodes of a particular season of web-series are released simultaneously (2) . in the current situation of covid-19 pandemic with a global lockdown state, as people have little to do, there seems to be an increase in bingewatching. to the best of our knowledge, no study studied binge-watching behavior during pandemics and their short-term as well as long-term effects. this study aimed to determine the binge-watching pattern of television, internet resources during this covid-19 lockdown in south east asian countries. this is a descriptive study with a cross-sectional design. it was conducted in the general population of four southeast asian countries (bangladesh, india, indonesia & nepal). an online survey was conducted on the general population using the google form, who understand english. the study questionnaire contained 26 items. participants age 18 years and more, consenting to participate in the study and able to understand english were included in the study. the data were analyzed in terms of percentages, mean, standard deviation and proportions. also, country-wise comparison done. a total of 551 individuals who participated in the survey, of two, were excluded because of not meeting the age criteria and one excluded due to incomplete data. the final analysis was done in a sample of 548 participants. a total of 548 adults (age ≥18years) sample was analyzed, out of which 61.3 % of participants were from india, 22.3 % from nepal, 10.2 % from bangladesh and 6.2 % from indonesia. the mean age of the sample was 32.62 (±10.29), 60% were males, 44% were graduates (44.3 %), 40.5% postgraduates, most of them belonged to the nuclear family (74.6 %) and are presently living with family (81.2%), and 53.3% had been working from home ( table 1 ).the previous history and pattern of viewing tv/ online videos indicate that most of the population watched frequently but for a shorter duration (38.7%) and the average time for binge-watching was 1-3 hours (68.8 %). during the lockdown period, 73.7 % agreed to a considerable increase in binge-watching with an increase in an average time of 3-5 hours (17.3 %) and 5+ hours (11.5 %) of binge-watching. the major platform used for viewing has been you-tube (52.7 %) and the major content watched has been news (69.2 %). the frequency of binge-watching has been daily for 27.6% of participants. interference caused due to binge-watching indicates that sometimes 39.1 % of participants experienced sleep disturbance, 32.3 % of participants sometimes missed work and 28.1% of participants reported sometimes having a conflict with others due to binge-watching. a total of 27.6 % reported that they have tried controlling their binge-watching but have failed to do so. the assessment of insight about bingewatching indicates that 30.3% of participants sometimes feel that they are getting addicted as well as 43.2% of the participants report that they try controlling their bingewatching behavior and 29% fear that binge-watching will interfere in their future work. regarding the consequence of binge-watching, 69.5 % of participants report that bingewatching is bad for them although 46.7% of the participants were unaware of the concept of binge-watching. most of the participants (52.6 %) report the major psychological motivation for binge-watching as to pass time and escape boredom, 25% use it for relieving stress as well as 15.7 % use it for overcoming loneliness. on the other hand, 30.8 % of the population report that they watch tv/ online videos to keep themselves updated. as the sources of entertainment and social interaction got limited during this pandemic, globally, people directed themselves to the readily available modes of entertainment in their home settings. it has been reported in recent day electronic and printed media that there is an increase in viewership of television and internet over the past few months, globally. during the lockdown period although more than half the participants (53.3 %) were found to be working from home yet most of them agreed that their tv/ internet usage has increased (73.7 %) considerably daily (27.6 %). this might indicate the use of binge-watching as a coping mechanism. it is considered an unhealthy coping mechanism as people tend to substitute the live unacceptable experiences with fantasy and imagination generating web-series and television shows (3). the psychological motivation found for binge-watching has been to pass time and escape boredom (52.6 %), relieve stress (25 %), overcome loneliness (15.7%). it leads to the immediate gratification of needs. the constant availability of content for binge-watching helps in the gratification of needs whenever and wherever one wants, resulting in an imbalance between the short-term pleasures and the potential costs of media exposure (4). it is too early to say whether binge-watching will result in behavioral addiction or not. however, existing evidence supports the association of binge-watching with mood disturbances, sleep disturbances, fatiguability and impairment in self-regulation (5). this study revealed that binge-watching sometimes causes significant interference in sleep (39.1 %), disturbs in completion of work (32.3 %) as well as causes conflict with others (28.1 %) (table 1) . further, research is required to establish a cause-effect relationship. but, as per the existing evidence, limiting the binging behavior may be beneficial for people and may prevent the development of lifestyle-related disorders too. this study is an attempt to understand the possible cyber-psychopathologies during covid 19 pandemic. there is a need to look for the long-term effect of binge-watching in the general population, which will give a better insight into understanding the pathological aspects of bingewatching behavior. the emotional impact of coronavirus 2019-ncov (new coronavirus disease) binge-watching: a matter of concern? stress, appraisal, and coping key: cord-260585-ovmko655 authors: sherman, allen c.; williams, mark l; amick, benjamin c; hudson, teresa j.; messias, erick l title: mental health outcomes associated with the covid-19 pandemic: prevalence and risk factors in a southern us state date: 2020-09-24 journal: psychiatry res doi: 10.1016/j.psychres.2020.113476 sha: doc_id: 260585 cord_uid: ovmko655 the covid-19 pandemic has had a dramatic effect on the functioning of individuals and institutions around the world. this cross-sectional registry-based study examined some of the burdens of the pandemic, the prevalence of mental health difficulties, and risk factors for psychosocial morbidity among community residents in arkansas. the study focused on a period of gradual reopening but rising infection rates. the investigation included validated screening measures of depressive symptoms (phq-9), generalized anxiety (gad-7), trauma-related symptoms (pcl-5), and alcohol use (audit-c). a notable percentage of participants reported elevated symptoms on each of these outcomes. in separate multivariable analyses that accounted for a number of demographic and pandemic-related covariates, individuals who reported greater pandemic-related disruption in daily life, and those with a prior history of mental health concerns, were more likely to screen positive for depressive, anxiety and trauma-related symptoms. findings illuminate burdens experienced by community residents during a period of phased reopening, and offer a foundation for future screening and intervention initiatives. in the period since january 2020, when the world health organization (who, 2020) and the us department of health and human services (health and human services, 2020) designated the coronavius disease (covid-19) as a public health emergency, the pandemic has had a sweeping impact on daily life for individuals around the world. the high transmissibility of the virus in conjunction with the lack of approved vaccines and limited therapeutics have contributed to an international public health crisis. communities have had to manage shortages of viral testing resources, diminished access to routine medical care, and sometimes conflicting preventative health recommendations. physical distancing provisions have constrained access to work and recreation. the jarring economic effects have left many individuals unemployed or with reduced incomes, and almost everyone has grappled with disruptions in normal routines. these widespread changes might contribute to a range of psychosocial difficulties, including social isolation, anxiety, uncertainty, and loss. there have been urgent calls for research regarding potential mental health effects of the covid-19 pandemic (holmes et al., 2020) . as yet, relatively little is known about responses among the general population in the us (liu et al, 2020; tull et al, 2020) , though work in this area is advancing rapidly. an initial wave of studies, mostly conducted in the immediate aftermath of the outbreak, suggested elevated levels of selfreported anxiety, depressive symptoms, and distress among community residents in china (e.g., huang and zhao, 2020; qiu et al. 2020; ren et al., 2020; tang et al. 2020; zhang and ma, 2020) and then in other countries such as italy (forte et al., 2020; germani et al., 2020) , spain (gonzalez-snguino et al., 2020) , germany (bäuerle et al., 2020b; petzold et al., 2020) , india (varshney et al. 2020) , egypt (el-zoghby eta l. 2020), hong kong (choi et al., 2020) , and the us (liu et al. 2020; tull et al., 2020) . earlier studies similarly documented mental health sequelae following the severe acute respiratory syndrome (sars) coronavirus epidemic, though these data were derived largely from recovered patients rather than the broader community (gardner and moallef, 2015) . a larger, well-developed literature has focused on psychosocial responses to other types of community-level disasters, with findings pointing to consistent problems with depression and trauma-related symptoms, sometimes in tandem with other difficulties such as anxiety, substance use, and general distress (beaglehole et al. 2018 , lowe et al. 2019 pietrazk et al., 2012; tang et al., 2017 ) . the extent to which these difficulties might be associated with the evolving covid-19 pandemic in the us remains uncertain, and clearly there is a need for additional research. moreover, as yet very few investigations that have focused specifically on the experience of the general public during periods of phased reopening of businesses and institutions (tan et al., 2020) . such research would be especially important in communities experiencing increased infection rates, where residents have struggled with the dilemma of increased access and social interaction but also increased risk. another salient concern involves efforts to identify which individuals may be most vulnerable to psychosocial morbidity in response to the pandemic. it is recognized that periods of upheaval affect different individuals in different ways (mancini, 2020) . risk factors identified thus far in prior research regarding responses to the covid-19 pandemic included female gender, younger age, and a previous history of mental health concerns (bäuerle et al. 2020b; el-zoghby et al., 2020; forte et al., 2020; germani et al., 2020; gonzales-sanguino, 2020; rossi et al., 2020; solomon and constantinidou, 2020; varshney et al., 2020) . specific aspects of the pandemic might be expected to increase vulnerability to distress as well, including viral exposure or infection, financial adversity, food insecurity, diminished access to healthcare, greater isolation associated with social distancing efforts, and increased disruption in daily life. different geographic regions have encountered notable differences over time in sars-cov2 viral infection rates and local government mitigation responses. the current study was a registry-based cross-sectional investigation regarding mental health responses to the covid-19 pandemic among community residents in arkansas. rural regions have been identified as among the populations of special interest (holmes et al., 2020) , though as yet rural areas of the us have not been studied. we sought to examine a number of clinically relevant psychosocial outcomes that might be adversely affected by a global traumatic event (i.e., elevated symptoms of depression, generalized anxiety, posttraumatic stress, and alcohol misuse), using validated self-report screening measures. additionally, we evaluated a range of demographic and situational risk factors that might intensify vulnerability to psychosocial morbidity. we anticipated that heightened levels of anxiety, depression, and posttraumatic stress would be associated with specific situational factors, including perceived viral exposure or infection, food and financial insecurity, reduced access to routine medical care, greater disruption in daily life, more stringent social distancing, and diminished daily structure. this was a cross-sectional registry-based observational study. the online survey was available for one month from may 22 nd to june 24 th , a period during which infection rates in arkansas increased significantly (centers for disease control and prevention, 2020) while the state progressively reopened (phase 1 and early phase 2 in arkansas). emailed invitations with links to the online survey were distributed to individuals in the arresearch registry, which is comprised of individuals who have expressed potential interest in research participation, and which varies widely with respect to rural vs. urban residence, socioeconomic resources, and racial/ethnic background. the registry is maintained by the translational research center at the university of arkansas for medical sciences (uams). individuals were included if they were age 18 and older, resided in the state, and were listed in the registry as healthy community residents. an information form informed potential participants about study procedures, risks, and confidentiality provisions, and the return of the completed survey signified consent. the study was approved by the uams institutional review board with a waiver of documentation of written consent. the survey was administered using redcap, a secure web application for online research which allows participants to enter responses online (harris et al., 2009) . to enhance comparability across other studies in progress, instruments were derived as much as possible from those posted kroenke et al., 2001 ) was used to assess depressive symptoms. the reliability and construct validity of this screening instrument have been reported in multiple investigations (kroenke et al., 2001 , levis et al., 2019 . a cutoff score ≥10 has shown a sensitivity of 88% and a specificity of 85% for major depression in a meta-analysis of findings derived from a variety of medical and nonmedical settings (levis et al., 2019) . the 7-item generalized anxiety disorder questionnaire (gad-7; spitzer et al., 2006) was used to measure generalized anxiety. studies in primary care patients (spitzer et al. 2006 ) and the general population (lowe et al. 2008 ) have supported the reliability and criterionrelated validity of this measure. in a meta-analysis, a cutoff score of 10 demonstrated a sensitivity of 83% and specificity of 84% among individuals assessed in medical and community settings (plummer et al., 2016) . the 20-item ptsd checklist for dsm-5 (pcl-5; blevins et al., 2015) was used to evaluate trauma-related symptoms (blevins et al. 2015) . instructions were keyed to the covid-19 pandemic. research suggests good internal consistency and convergent validity in student and clinical populations. a cut-off value of 33 has been viewed as an indicator of posttraumatic stress (blevins et al. 2015; bovin et al., 2015) . (our interest was in trauma-related symptoms; given the ongoing nature of the pandemic at the time of assessment no effort was made to assess temporal criteria for acute stress disorder or posttraumatic stress disorder.) the 3-item audit-c (bush et al., 1998) was used to assess alcohol use, as a secondary outcome. this measure has been widely used to screen for alcohol misuse. cut-off scores of ≥4 for men and ≥3 for women have been used as indices of heavy alcohol use (bush et al., 1998; bradley et al., 2007) . participants completed a brief form regarding demographic characteristics (e.g., age, gender, ethnicity, prior medical and mental health conditions, etc. year follow-up study (marel et al., 2020) . items inquired about covid-19 testing and perceived infection, using items adapted from the uas, and about perceived exposure and perceived covid-19 symptom severity, using items adapted from the atos. three items (coded no, yes, not sure) inquired about food insecurity (i.e., -worried that you would run out of food;‖ -ate less than you think you should;‖ or -went without eating for a whole day‖), and 2 items asked about financial insecurity (i.e., missed or delayed payment of rent/mortgage and utility bills), using items adapted from the uas. eight items (coded no, yes, not sure) assessed social activity/distancing behaviors (e.g., -attended a gathering with more than 10 people‖), using items adapted from the uas; these items were summed to create a total score. a series of 7 items, created by the authors, assessed disruptions in daily life due to the pandemic (e.g., -trouble arranging for childcare,‖ -trouble staying involved with family/friends‖); each item was rated on a 4-point likert scale and summed to derive a total score. four single items, each with 4-5 response options, asked about other burdens, including illness or loss of loved ones due to covid-19, and the impact of the pandemic on employment status, daily structure, and sheltering at home. additional items regarding healthcare assessed whether the pandemic had affected access to usual medical care, and whether participants had sought psychotherapy or psychiatric medication in response to the pandemic (each coded no, yes, not sure). finally, participants were asked about prior (pre-pandemic) mental health concerns, including a history of depression, anxiety, and ptsd diagnoses (each coded no, yes, not sure). descriptive statistics were used to summarize demographic variables and to characterize covid-related burdens. using established cut-off scores, we examined the frequency (percentage) of participants who screened positive for possible cases of depression (phq-9), generalized anxiety (gad-7), posttraumatic stress (pcl-5), and alcohol misuse (audit-c). preliminary bivariate analyses evaluated associations of elevated scores on the primary outcomes (i.e., scores above thresholds for depression, anxiety, and trauma) with demographic variables (e.g., age, ethnicity, gender, comorbidities) and situational risk factors (e.g., perceived exposure and infection, covid-19 symptoms, food and financial insecurity, access to routine medical care, pandemic-related employment changes, illness or loss of loved ones, reduced daily structure, social activity, and disruption in daily activities,), using t-tests, or chi-square or fisher exact tests, as appropriate. due to its non-normal distribution, a logarithmic transformation was used for the level of disruption in daily life; however, results were unchanged using the raw score, so the raw score is reported here for ease of interpretation. several variables were dichotomized for the analysis, including marital status (married/living with partner vs. all others), ethnicity (minority group vs. non-minority), number of comorbidities (0 vs. 1 or more), food insecurity (no vs. yes to any of 3 items), financial insecurity (no vs. yes to any of 2 items), perceived viral exposure (none vs. significant or prolonged exposure at work, in the community, or at home), perceived viral infection (no vs. yes or not sure), perceived covid-19-related symptoms (none vs. mild, moderate, or severe), illness/death of loved ones (not affected vs. covid-19 illness or death of a loved one), pandemicrelated employment changes (no adverse changes vs. loss of job, loss of business, temporary lay-off, or reduction in hours/income), sheltering at home (sheltering and working at home and leaving no more than a few times per week vs. more frequent departures), and daily structure (few planned or scheduled activities vs. at least several planned/scheduled activities per week). separate multivariable logistic regression analyses were used to model associations of each outcome with demographic/situational factors that were significant in preliminary bivariate analyses. the data were checked for multicollinearity and residuals were examined. as partial adjustment for multiple comparisons p-values <.01 were considered significant. a total of 591 individuals (35.3%) responded to survey, completed the mental health measures and were included in the analyses, of 1672 who were sent emailed invitations. compared with those who not complete the survey, respondents were more likely to older (p =.001) and white (p =.001), and marginally more likely to be female (p = .011). data from 52 (8.72%) participants were missing for the pcl-5 (which was located at the end of the survey); individuals who did not complete this measure did not differ from those who did on any of the demographic or outcome variables (all p's >.08). missing data for all of the remaining variables was negligible (i.e., 0.05%). sample characteristics are listed in table 1 activities. the percentage who had experienced illness or death of a loved one from the disease was small (n = 38, 6.43%). interestingly, in response to the stress of the pandemic, a number of participants reported that they had sought mental health counseling (n =43; 7.28%) or had been started on psychiatric medication (n = 27, 4.57%). bivariate associations of the primary mental health outcomes with demographic and situational factors are displayed in tables 3 and 4 . with respect to demographic correlates, younger individuals (all p's ≤.0002), women (all p's ≤.005), and participants with lower family incomes (all p's ≤.003) were significantly more likely to screen positive for depression and anxiety (but not trauma symptoms), and those who reported a prior history of mental health diagnoses (all p's ≤.0001) were more likely to screen positive on all three mental health outcomes. individuals with a greater number of medical comorbidities (p =.005), less education (p =.005), and those who were not married or living with a partner (p =.002) were significantly more likely to report clinically elevated levels of depressive symptoms. in bivariate analyses, participants who experienced greater disruption in daily life due to the pandemic (all p's ≤.0002), and those who believed or suspected that they had been infected with the virus (all p's ≤.0005), were significantly more likely to screen positive on all three outcomes ( this study offers an initial evaluation of mental health outcomes in response to the covid-19 pandemic among community residents in arkansas. findings provide novel information regarding the experience of individuals in a rural southern region of the us. additionally, this investigation is among the first to characterize a period of phased reopening, during which infection rates continued to grow appreciably. results indicate that a notable proportion of respondents experienced clinically elevated distress, as assessed by validated screening measures of depressive symptoms, generalized anxiety symptoms, trauma-related symptoms, and alcohol use. these levels would appear to exceed prevalence estimates derived from the general us population prior to the pandemic (kessler et al., 2005) , though the population estimates are based on diagnostic interviews rather than more provisional self-report instruments. findings suggest that mental health difficulties are a salient concern in the post-acute period of the pandemic-that is, during an interval of gradual reopening of businesses and venues within the state (phases 1 and 2) but progressively mounting cases of infection. (choi et al., 2020) reported that 14.4 to 19.8% of participants had exceeded cut-off values for depression on the phq-9 or briefer phq-2, and 14.0 to 21.6% had exceeded thresholds for generalized anxiety on the gad-7 or gad-2; these estimates are in range with the values found here (i.e., 20.8% for depression and 16.6% for anxiety). prevalence rates were notably higher in an american study conducted with young adults earlier in the pandemic (43.3% and 45.4%, respectively), which is perhaps not surprising given the association between younger age and heightened distress (liu et al, 2020) . as yet, few studies have used any version of our measure of trauma symptoms (pcl-5); among those that have, findings have been quite variable but higher than our estimate of 5.4% (gonzalez-sanguino et al., 2020; liu et al., 2020) . no comparisons are available as yet regarding our measure of alcohol use (audit-c). as anticipated, in bivariate analyses we found that younger participants, women, and individuals with lower incomes were more likely to screen positive for depression and anxiety (though not trauma symptoms), and those who had received a prior mental health diagnosis (i.e., mood disorder, anxiety, or ptsd) were at higher risk for all three psychosocial outcomes. . results regarding other demographic correlates have been inconsistent in prior research. we did not find strong effects for racial/ethnic background. nonetheless, given that minority groups face greater risks for covid-19 complications and mortality (khunti, 2020) , as well as broader inequities in healthcare, it seems clear that potential mental health sequelae in minority communities continue to merit close attention. consistent with hypotheses, several aspects of the pandemic were related to poorer outcomes in bivariate analyses. individuals who believed (or were unsure) that they had been infected were more likely to screen positive on all three mental health outcomes, and those who perceived that they had experienced physical symptoms of covid-19 were more likely to screen positive for depression and anxiety. (the number of participants who had received actual test results was too small to support meaningful analyses for viral status.) as anticipated, individuals who experienced food insecurity or financial insecurity were more likely to screen positive for depression and anxiety (with a non-significant trend for trauma symptoms). loss of income or employment was related to greater risk for depression and trauma symptoms. these results are a notable concern, given the breadth of the economic crisis precipitated by the pandemic, and underscore the need to address the mental health costs of economic turmoil. participants who experienced reduced access to routine health care were more likely to report elevated depression and anxiety symptoms. the gradual resumption of services by primary and specialty care clinics, facilitated in part by broader use of telemedicine platforms, might help diminish these concerns over time. fundamental changes in the fabric of daily life were also related to mental health difficulties. individuals who had the least structure in their daily lives, with fewer planned or scheduled activities to organize their day, were more likely to screen positive for depression and anxiety, while those who were more stringent in their efforts to shelter at home, seldom leaving their residence, were more likely to screen positive for depression and trauma symptoms. moreover, greater disruption in daily life (as reflected in difficulties caring for others for whom one is responsible, arranging childcare, sustaining activities or religious pursuits, maintaining valued connections with family and friends, etc.) was associated with greater likelihood of clinically elevated distress on all three outcomes. these findings are consistent with concerns that have been expressed about the adverse effects of ruptured routines, responsibilities, and social ties in the aftermath of the pandemic (holmes et al., 2020; tull et al., 2020) . multivariable analyses, which accounted for the effects of each of these demographic and situational risk factors, suggested that vulnerability to clinically meaningful depression was highest among individuals with a prior history of mental health problems, those who were unmarried, and those who experienced greater disruption in daily life due to the pandemic. risks for generalized anxiety were highest among community residents who had a prior mental health history, lower incomes, and who experienced greater disruption in daily life. similarly, the likelihood of elevated trauma symptoms was most pronounced among those with prior mental health diagnoses and greater disruption in daily life stemming from the pandemic. current results, in conjunction with findings from other studies reviewed here, suggest a need to marshal a range of pragmatic, accessible mental health services across the spectrum of care from prevention through screening and treatment. the need may be acute in view of an anticipated surge in demand for mental health care in response to the pandemic (figueroa and aguilera, 2020) , especially in regions such as arkansas struggling with protracted problems with disease mitigation, or those subjected to subsequent waves of infection. internet-based services are expected to play a major role; evidence supports the efficacy of interventions delivered on digital platforms (e.g., andersson et al., 2014) and smartphone applications (e.g., firth et al., 2017) . in the us and a number of other countries, barriers to billing for telehealth services have been reduced, but there remain racial and age-related disparities in digital literacy and access to technology (figueroa and aguilera, 2020) . there have been preliminary efforts to develop interventions specifically geared toward the challenges of the pandemic (e.g., bäuerle et al., 2020a; figueroa and aguilera, 2020; sanderson et al., 2020; wei et al., 2020) , and these initiatives can be expected to grow. this study is among the first to examine mental health outcomes among community residents in arkansas, and one of the few investigations to use validated screening tools to evaluate these outcomes in the us. on average, the sample is older than those evaluated in many prior studies, which offers novel information about the experiences of individuals at increased risk for covid-19-related mortality. the large sample, range of clinically relevant outcomes, and detailed attention to pandemic-related risk factors are among the salient features of the study. moreover, extensive efforts were made to select established measures that would allow for comparisons with future investigations. the study has important limitations as well. the cross-sectional design precludes any inferences about casual or temporal relationships (e.g., it is possible mental health difficulties contributed to greater financial insecurity or more stringent sheltering at home, rather than vice versa). further research is needed to examine changes in these outcomes over time, especially in view of the rapidly evolving nature of local infection rates, mitigation efforts, and economic disruptions. additionally, the sample was drawn from a research registry, and though it was racially, economically, and geographically diverse, it is not a representative sample of the population. women were overrepresented, which is common in survey studies (bäuerle et al., 2020b; forte et al., 2020; germani et al., 2020; gonzaelz-sanguino et al, 2020) , and african americans and younger individuals were under-represented relative to the state population. the response rate was modest (35%), though in keeping with rates often observed in web-based community surveys (mcconnell et al., 2006; porter & whitcomb, 2003; sinclair et al., 2012) . to address these issues regarding selection bias and cross-sectional analyses, population-based studies using longitudinal designs would offer an important contribution at the next phase of research; such work is underway. scores on self-report screening measures are not the same as clinical diagnoses; in subsequent investigations it would be useful to include information derived from diagnostic interviews. finally, other variables that might be associated with mental health outcomes merit attention in future research, including level of media exposure, perceptions of personal risk, safety provisions associated with return to work, and attitudes toward vaccination. in sum, results suggest heightened levels of psychiatric morbidity during a period of reopening in response to the covid-19 pandemic, among community participants in a rural southern us state. individuals who struggle with greater interference in their day-to-day lives, and those with preexisting mental health difficulties, may be most vulnerable to mental health sequelae. author contributions: we declare that we do not have any commercial or associative interest that represents a conflict of interest in connection with the work submitted. the project described was supported by the translational research institute (tri), grant ul1 tr003107 through the national center for advancing translational sciences of the national institutes of health (nih). the content is solely the responsibility of the authors and does not necessarily represent the official views of the nih. guided internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: a systematic review and meta-analysis an e-mental health intervention to support broadened people in times of the covid-19 pandemic: cope it increased generalized anxiety, depression, and distress during the covid-19 pandemic: a cross-sectional study in germany psychological distress and psychiatric disorder after natural disasters: systematic review and meta-analysis the posttraumatic stress disorder checklist for dsm-5 (pcl-5): development and initial psychometric evaluation psychometric properties of the ptsd checklist for diagnostic and 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risk factors for post-traumatic stress disorder (ptsd) in adults and children after earthquakes covid-19 related depression and anxiety among quarantined respondents. psychol health psychological outcomes associated with stay-at-home orders and the perceived impact of covid-19 on daily life uas) coronavirus tracking survey, long form survey instrument-wave 2 initial psychological impact of covid-19 and its correlates in indian community: an online (feel-covid) survey efficacy of internet-based integrated intervention on depression and anxiety symptoms in patients with covid-19 world health organization. who director-general's statement on ihr emergency committee on novel coronavirus (2019-ncov). world health organization website impact of the covid-19 pandemic on mental health and quality of life among local residents in liaoning province, china: a cross-sectional study key: cord-333974-mvo2k2jt authors: mcintyre, roger s.; lee, yena title: projected increases in suicide in canada as a consequence of covid-19 date: 2020-05-19 journal: psychiatry res doi: 10.1016/j.psychres.2020.113104 sha: doc_id: 333974 cord_uid: mvo2k2jt macroeconomic indicators, notably unemployment, are significant moderators of suicide. we projected the number of excess suicides in canada as a consequence of the impact of covid-19 on unemployment. annual suicide mortality (2000-2018) and unemployment (2000-2019) data were derived from statistics canada. time-trend regression models were used to evaluate and predict the number of excess suicides in 2020 and 2021 for two possible projection scenarios following the covid-19 pandemic: 1) an increase in unemployment of 1.6% in 2020, 1.2% in 2021, or 2) an increase in unemployment of 10.7% in 2020, 8.9% in 2021. a percentage point increase in unemployment was associated with a 1.0% increase in suicide between 2000-2018. in the first scenario, the rise in unemployment rates resulted in a projected total of 418 excess suicides in 2020-2021 (suicide rate per 100,000: 11.6 in 2020). in the second scenario, the projected suicide rates per 100,000 increased to 14.0 in 2020 and 13.6 in 2021, resulting in 2,114 excess suicides in 2020-2021. these results indicate that suicide prevention in the context of covid-19-related unemployment is a critical priority. furthermore, timely access to mental healthcare, financial provisions and social/labour support programs, as well as optimal treatment for mental disorders is urgently needed. as a consequence of the covid-19 pandemic, approximately one-third of the global population currently resides under some form of lockdown or quarantine. the impact of the containment measures on the global economy is projected to dwarf the macroeconomic impact of the 2008-09 financial crisis in both magnitude and scope (oecd economics department, 2020) . unprecedented proportions of the employment sectors in the usa and canada have filed for unemployment benefits. statistics canada reported, on april 9, 2020, that one-in-ten working-age individuals (i.e., fifteen years of age and over) in canada lost their jobs or worked less than half their usual hours as a result of the widespread restrictions imposed in march 2020 (government of canada, statistics canada, 2020). suicide rates, at a population-level, are highly sensitive to macroeconomic indicators, particularly unemployment (chang et al., 2009; reeves et al., 2012; stuckler et al., 2009) . we recently reported that the rapid rise in unemployment as a result of the covid-19 pandemic is predicted to result in 3, 164 excess suicides between 2020 and 2021, representing a 3.3-8.4% increase in suicides per year from the 2018 rate of 48,432 suicides in the usa (mcintyre and lee, 2020). during the great recession, an increase in the number of suicides was also reported in canada (reeves et al., 2014) . herein, we replicate and extend our previous findings and project the number of excess suicides in canada as a consequence of the impact of covid-19 on unemployment. annual, national-level suicide mortality (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) (2008) (2009) (2010) (2011) (2012) (2013) (2014) (2015) (2016) (2017) (2018) and unemployment (2000-2019) data were acquired from statistics canada (government of canada, statistics canada, 2019 , 2018 . the vital statistics -death database records the number of deaths due to suicide among canadian residents and non-residents in canada. suicide rate per 100,000 was codified using international statistical classification of diseases and related health problems, 10th revision (icd-10) codes for intentional self-harm (i.e., x60-x84, y87.0). the labour force survey collects cross-sectional unemployment data with stratified multi-stage sampling and a rotating panel sample design (i.e. rotation groups of six consecutive months). this research was based on publicly available data and therefore did not require ethics approval. time-trend regression models were used to evaluate and predict the number of excess suicides attributable to the projected rise in unemployment rate following the covid-19 pandemic. first, we modelled the number of suicide detahs annually between 2000 and 2018 and the association between suicide and unemployment rates. second, we estimated the number of suicide deaths in 2019 using the time-trend model and the published unemployment rate of 5.7% for 2019. third, we predicted the number of suicide deaths in 2020 and 2021 for the three following scenarios: 1) minimal change in unemployment (i.e., average annual unemployment rate of 5.9% in 2020, 6.0% in 2021; derived from the 2019 federal budget); 2) moderate increase in projected unemployment rate (i.e., average annual unemployment rate of 8.3% in 2020, 8.1% in 2021), as forecasted by the international monetary fund based on the assumption that the pandemic will fade in the second half of 2020 that there will not be a second outbreak in 2021; and 3) extreme increase in projected unemployment rate (i.e., average annual unemployment rate of 16.6% in 2020, 14.9% in 2021), approximating the peak unemployment rate of 19% during the great depression (government of canada, department of finance, 2019; "world economic outlook, april 2020 --chapter 1: the great lockdown," 2020). we quantified the number of excess suicide deaths associated with a moderate increase in unemployment by subtracting the number of suicide deaths estimated in the first scenario from the number of suicide deaths in the second scenario. similarly, we quantified the number of excess suicide deaths associated with an extreme increase in unemployment by subtracting the number of suicide deaths estimated in the first scenario from the number of suicide deaths in the third scenario. the suicide rate per 100,000 and the unemployment rate were ln-transformed. the analyses were conducted using the functions ts from the package stats and auto.arima and forecast from the package forecast on r statistical software version 3.6.3 (hyndman et al., 2020; hyndman and khandakar, 2008; r core team, 2020) . the historical suicide rates for 2000-2018 and the projected suicide rates for 2019-2021 are visualized in in the first scenario, wherein unemployment rates change minimally between 2019 and 2021, the predicted suicide rates are 11.0 per 100,000 in 2020 and 2021 (table 1) . the foregoing suicide rates would result in 4,127 suicides in 2020 and 4,143 in 2021 (assuming 2019 population size of 37,589,262). in the second scenario, wherein the pandemic is contained and lockdown measures are lifted during the latter half of 2020, moderate increases in projected unemployment rates to 7.5% in 2020 and 7.1% in 2021 will increase the forecasted suicide rates per 100,000 from 10.9 in 2019 to 11.6 in 2020 and 11.5 in 2021. this second scenario would result in a total of 418 excess suicides over the 2020-2021 period, representing a 5.5% increase in suicides per year (when compared to the 2018 rate of 3,811). in the third scenario (i.e., extreme increase in projected unemployment rate), suicide rates per 100,000 are projected to increase to 14.0 in 2020 and 13.6 in 2021. this rise in suicide rate would result in 2,114 excess suicides over the two-year period, representing a 27.7% increase in suicides per year (relative to the 2018 suicide rate). the results of our projection analysis are in accordance with what we previously discovered in a similar analysis in the usa that the abrupt increase in unemployment in canada is associated with an increase in deaths due to suicide. the projection estimates we have observed are also similarly aligned with what was observed in canada during the great recession (reeves et al., 2014) . we recognize that no single variable accounts for completed suicide within individuals or populations. we additionally recognize that no single macroeconomic indicator is sufficiently predictive of suicide. notwithstanding, it was observed during the great recession in the usa, canada, and various economies of europe, as well as asia, that the change in unemployment rate was highly associated with increase in suicide rates (chang et al., 2009; reeves et al., 2014 reeves et al., , 2012 stuckler et al., 2009) . moreover, the association between economic distress and adverse mental health outcomes, notably suicide, is a highly replicated observation (alicandro et al., 2019; collins et al., 2020) . the covid-19 pandemic introduces other aspects that are detrimental to mental health not seen during the great recession and other economic downturns, notably the risk of viral infection, as well as social distancing and quarantine measures. a separate body of literature indicates that quarantine alone is an independent contributor to adverse mental health outcomes (e.g., post-traumatic stress symptoms), as observed during the sars epidemic in toronto in 2013 (brooks et al., 2020) . it was reported in several countries in europe after the great recession (e.g., denmark) that social spending on emergency healthcare/mental healthcare, wage subsidies, supplemental income, and work retraining mitigated risk of suicide (peeples, 2019) . it was also reported in japan, as well, during the great depression, that increased social spending significantly mitigated suicide completion (matsubayashi et al., 2020) . the results of our analysis underscore the urgency of prioritizing access to mental healthcare and the provision of psychological first aid. the covid-19 pandemic has accelerated the implementation of telemedicine/telehealth; clinicians are encouraged to incorporate the assessment of mental health amongst all patients including, but not limited to, those previously diagnosed with mental illness. social isolation measures are critical to reduce the spread of the coronavirus and a recently conducted analysis also indicates that during the great depression those cities in the usa that had the most rapid and robust social isolation measures also witnessed the greatest economic rebound (stuckler et al., 2009) . a policy approach to managing the covid-19 pandemic needs to be informed by the projection of possible suicides to prevent excess suicides in the context of the covid-19 pandemic. we see a role for primary, secondary, and tertiary prevention. for example, wage subsidies, forbearance on financial obligation, government support of small business, work retraining programs, and access to community-based support programs can all serve as primary prevention. we also believe that the creation of virtual, as well as conventional, services that provide timely access to high quality mental health assessment and, where appropriate, specific treatment for persons at risk of mental illness are urgently needed. finally, we assert that specialized services with an emphasis on psychiatric first aid available in communities and co-localized with other medical services will be especially relevant as a mechanism to reduce suicide at this time. suicide mortality in 2020 and 2021 were projected for three scenarios of change in unemployment rates: no change (i.e., 5.9% in 2020 and 6.0% in 2021 as published in the 2019 federal budget), moderate increase (i.e., 7.5% in 2020, 7.2% in 2021), and extreme increase (i.e., 16.6% in 2020, 14.9% in 2021). worldwide trends in suicide mortality from 1990 to 2015 with a focus on the global recession time frame the psychological impact of quarantine and how to reduce it: rapid review of the evidence was the economic crisis 1997-1998 responsible for rising suicide rates in east/southeast asia? a time-trend analysis for japan suicide, sentiment and crisis labour force characteristics by sex and detailed age group, annual [www document]. government of canada deaths and age-specific mortality rates, by selected grouped causes forecast: forecasting functions for time series and linear models automatic time series forecasting: the forecast package for r government spending, recession, and suicide: evidence from japan preventing suicide in the context of the covid-19 pandemic evaluating the initial impact of covid-19 containment measures on economic activity how the next recession could save lives r: a language and environment for statistical computing economic suicides in the great recession in europe and north america increase in state suicide rates in the usa during economic recession the public health effect of economic crises and alternative policy responses in europe: an empirical analysis the great lockdown abbreviations: ci = confidence interval, ur = unemployment rate. key: cord-323482-kk8iyavj authors: muller, researcher ashley elizabeth; hafstad, senior advisor elisabet vivianne; himmels, senior advisor jan peter william; smedslund, senior researcher geir; flottorp, research director signe; stensland, researcher synne øien; stroobants, scientific coordinator stijn; van de velde, researcher stijn; elisabeth vist, senior researcher gunn title: the mental health impact of the covid-19 pandemic on healthcare workers, and interventions to help them: a rapid systematic review date: 2020-09-01 journal: psychiatry res doi: 10.1016/j.psychres.2020.113441 sha: doc_id: 323482 cord_uid: kk8iyavj the covid-19 pandemic has heavily burdened healthcare systems throughout the world. we performed a rapid systematic review to identify, assess and summarize research on the mental health impact of the covid-19 pandemic on hcws (healthcare workers). we utilized the norwegian institute of public health's live map of covid-19 evidence on 11 may and included 59 studies. six reported on implementing interventions, but none reported on effects of the interventions. hcws reported low interest in professional help, and greater reliance on social support and contact. exposure to covid-19 was the most commonly reported correlate of mental health problems, followed by female gender, and worry about infection or about infecting others. social support correlated with less mental health problems. hcws reported anxiety, depression, sleep problems, and distress during the covid-19 pandemic. we assessed the certainty of the estimates of prevalence of these symptoms as very low using grade. most studies did not report comparative data on mental health symptoms before the pandemic or in the general population. there seems to be a mismatch between risk factors for adverse mental health outcomes among hcws in the current pandemic, their needs and preferences, and the individual psychopathology focus of current interventions. the covid-19 pandemic has heavily burdened, and in many cases overwhelmed, healthcare systems 1 ,2 including healthcare workers. the who emphasized the extremely high burden on healthcare workers, and called for action to address the immediate needs and measures needed to save lives and prevent a serious impact on physical and mental health of healthcare workers 3 . previous viral outbreaks have shown that frontline and non-frontline healthcare workers are at increased risk of infection and other adverse physical health outcomes 4 . furthermore, healthcare workers reported mental health problems putatively associated with' occupational activities during and up until years after epidemics, including symptoms of post-traumatic stress, burnout, depression and anxiety [5] [6] [7] . likewise, reports of the mental toll on healthcare workers have persistently appeared during the current global health crisis [8] [9] [10] . several reviews have already been conducted on healthcare workers' mental health in the covid-19 pandemic, with search dates up to may 2020. pappa et al. 11 identified thirteen studies in a search on 17 april 2020 and pooled prevalence rates; they reported that more than one of every five healthcare workers suffered from anxiety and/or depression; nearly two in five reported insomnia. vindegaard & benros' 12 review, searching on 10 may 2020, identified twenty studies of healthcare workers in a subgroup analysis, and their narrative summary concluded that healthcare workers generally reported more anxiety, depression, and sleep problems compared with the general population. in the face of a prolonged crisis such as the pandemic, sustainability of the healthcare response fully relies on its ability to safeguard the health of responders: the healthcare workers 13 ,14 . yet, the recent findings of psychological distress among healthcare workers might indicate that the healthcare system is currently unable to effectively help the helpers. understanding the risks and mental health impact(s) that healthcare workers experience, and identifying possible interventions to address adverse effects, is invaluable. our main aim was to perform an updated and more comprehensive rapid systematic review to identify, assess and summarize available research on the mental health impact of the covid-19 pandemic on healthcare workers, including a) changes over time, b) prevalence of mental health problems and risk/resilience factors, c) strategies and resources used by healthcare providers to protect their own mental health, d) perceived need and preferences for interventions, and e) healthcare workers' understandings of their own mental health during the pandemic. our second aim was to describe the interventions assessed in the literature to prevent or reduce negative mental health impacts on healthcare workers who are at work during the covid-19 pandemic. we conducted a rapid systematic review according to the methods specified in our protocol, published on our institution's website 15 . we included any type of study about any type of healthcare worker during the covid-19 pandemic, with outcomes relating to their mental health. we extracted information about interventions aimed at preventing or reducing negative mental health impacts on healthcare workers; we were therefore interested in quantitative studies examining prevalence of problems and effects of interventions as well as qualitative studies examining experiences. we had no restrictions related to study design, methodological quality, or language. we identified relevant studies by searching the norwegian institute of public health's (niph's) live map of covid-19 evidence (https://www.fhi.no/en/qk/systematic-reviews-hta/map/) and database on 11 may 2020, as described in our protocol 15 . the live map and database contained 20,738 references screened for covid-19 relevance containing primary, secondary, or modelled data. two researchers independently categorized these references according to topic (seven main topics, 52 subordinate topics), population (41 available groups), study design, and publication type. we identified references categorized to the population "healthcare workers", and to the topic "experiences and perceptions, consequences; social, political, economic aspects". in addition, we identified references by searching (title/abstract) in the live map's database, using the keywords: emo*, psych*, stress*, anx*, depr*, mental*, sleep, worry, somatoform, and somatic symptom disorder. we screened all identified references specifically for the inclusion criteria for this systematic review. the protocol of the live map of covid-19 evidence describes the methodology of the map and database 16 the last included search for this review was conducted on 11 may 2020. the search strategy is presented in appendix 1. we developed a data extraction form to collect data on country and setting, participants, exposure to covid-19, intervention if relevant, and outcomes related to mental health. we extracted data on prevalence of mental health problems as well as correlates (i.e. risk/resilience factors); strategies implemented or accessed by healthcare worker to address their own mental health; perceived need and preferences related to interventions aimed at preventing or reducing negative mental health consequences; and experience and understandings of mental health and related interventions. one researcher (aem) extracted data and another checked her extraction. two researchers (aem, sf/gev) independently assessed the methodological quality of systematic reviews using the amstar tool 17 and of qualitative studies using the casp checklist 18 . one researcher (aem) assessed the quality of cross-sectional studies using either the jbi prevalence or the jbi cross-sectional analytical checklist, and longitudinal studies using the jibi cohort checklist 19 . results of these checklists are presented in appendix 2 in the standard risk of bias format. we summarized outcomes narratively. we describe interventions and outcomes based on the information provided in the studies. when studies presented prevalence rates out mental health outcomes in figures without numbers, we extracted numbers using an online software (https://apps.automeris.io/wpd/). we presented mean prevalence rates as box-and-whisker plots. we decided not to perform a quantitative summary of the associations between the various correlates and mental health factors, due to a combination of heterogeneity in assessment measures and lack of control groups, and an overarching lack of descriptions necessary to confirm sufficient homogeneity. our included studies not only varied greatly from one another, they most often did not report sufficient information regarding inclusion criteria, population, setting, and exposure to assess potential clinical heterogeneity. we graded the certainty of the evidence using the grade approach (grading of recommendations assessment, development, and evaluation 20 . fifty-nine studies were included. table 1 displays their summarized characteristics, while appendix 3 displays characteristics of the individual studies. a total of 54,707 participants were drawn from at least 34 separate countries across the studies (one study reported participants came from 91 countries, but did not specify these). the people's republic of china was the single most common setting (40 studies and 44,540 participants), followed by iran (four studies). setting was not applicable for the two systematic reviews and the review of online mental health surveys. the majority of studies (46) were cross-sectional surveys; two studies reported surveys administered twice over time; five were interview studies, of which three were analyzed qualitatively and two quantitatively; and four were other designs, including a case series and a study that searched within a database of existing online surveys. we also identified two systematic reviews 35 ,60 , which included five primary studies 8 ,29 ,42 ,44 ,69 . the studies reported on healthcare workers working in different settings: 42 studies reported on health care workers in hospitals, two studies were conducted in specialist health services outside hospitals, and three studies in other settings, while 21 studies did not specify the healthcare setting or only partially described multiple settings. no studies reported on nursing homes or primary care settings. in 40 studies, participants were frontline workers, while 26 studies reported on non-frontline workers. frontline or non-frontline activities were unclear in ten studies. six studies reported on interventions to reduce mental health problems. more than half of the studies included nurses (31) and/or doctors (33) . study sizes ranged from a case study with three participants to a survey of 11,118 participants. six studies reported on the implementation of interventions to prevent or reduce mental health problems caused by the covid-19 pandemic among healthcare workers. these interventions can be loosely divided into those targeting organizational structures, those facilitating team/collegial support, and those addressing individual complaints or strategies. two interventions involved organizational adjustments. the first intervention was reported on by two studies 28 ,37 . hong et al. 37 called it a "comprehensive psychological intervention" for frontline workers undergoing a mandatory two-week quarantine in a vocational resort, following two-to three-week hospital shifts. the quarantine itself was also described as part of the intervention, explicitly intended "to alleviate worries about the health of one's family". other elements included shortened shifts; involvement of the labor union to provide support to healthcare workers' families; and a telephone-based hotline that allowed healthcare workers to speak to trained psychiatrists or psychologists. this hotline had already been available to healthcare workers for four hours per week prior to the pandemic, but was made available for twelve hours, seven days a week. chen et al. 29 reported a second intervention that attempted to address individual complaints and facilitate collegial support. a telephone hotline was set up to provide immediate psychological support, along with a medical team that provided online courses to help healthcare workers handle psychological problems, and group-based activities to release stress. however, uptake was low, and when researchers conducted interviews with the healthcare workers to understand this, healthcare workers reported needing personal protective equipment and rest, not time with a psychologist. they also requested help addressing their patients' psychological distress. in response, the hospital developed more guidance on personal protective equipment, provided a rest space, and provided training on how to address patients' distress. schulte et al. 61 targeted collegial support and building individual strategies through one-hour video "support calls" for healthcare workers called in from their homes, to describe the impact of the pandemic on their lives, to reflect on their strengths, and to brainstorm coping strategies. this intervention was implemented as a response to the hospital redeploying pediatric staff to work as covid-19 frontline staff, and reorganizing pediatric space to accommodate more pediatric and adult covid-19 patients. none of the studies that implemented mental health interventions reported on the effects of the interventions on healthcare workers. the only data available to approximate the impact of the pandemic on the mental health of healthcare workers come from two longitudinal survey studies reporting on changes over time, both of low methodological quality. lv et al. 52 surveyed healthcare workers before and during the outbreak, reporting no further information about the timeline. the study included both those working on the frontline and those with unclear exposure to covid-19. however, it is unclear whether respondents were the same at both time points. the prevalence of anxiety, depression, and insomnia increased over time, whether mild, moderate, moderate to severe, or severe (see figure 2 ). during the outbreak, one out of every four healthcare workers reported at least mild anxiety, depression, or insomnia. ***insert figure 2 about here *** yuan et al. 73 and an increase in smoking and drinking for only 1%. the proportion reporting improvement was similar for fidgeting, fear, and feeling nervous and uneasy, and more improved in not thinking one can succeed and for a reduction in smoking and drinking. two cross-sectional studies reported healthcare workers' self-reported changes in mental health; both were also of low methodological quality due to insufficient reporting. in benham et al. 24 , twelve iranian psychiatry residents were re-deployed to work one frontline shift. half of the residents reported that they experienced more distress after this shift. abdessater et al. 21 ,22 studied 275 urology residents not working on the frontline. when asked to report the level of stress caused by covid-19, 56% reported a medium to high amount of stress, and the remaining reported none to low. less than 1% had initiated a psychiatric treatment during the pandemic. a third cross-sectional study 70 , also of low methodological quality, surveyed 60 healthcare workers in china in february, during the "outbreak period". a different cohort of 60 healthcare workers were surveyed in march, during the "non-epidemic outbreak period". the healthcare workers in to the second phase of the survey reported less symptoms of anxiety and depression, and higher health-related quality of life. twenty-nine studies reported prevalence data of mental health variables as proportions or percentages. (seventeen additional studies reported data as average scores on various instruments, and we did not extract this data.) we present box-and-whisker plots in figure 3 to show the distribution of anxiety, depression, distress, and sleeping problems among the healthcare workers investigated in the 29 studies, using the authors' own methods of assessing these outcomes the most commonly reported protective factor associated with reduced risk of mental health problems was having social support 48 ,58 ,69 ,74 . two studies directly measured self-perceived resilience. bohlken et al. 25 asked their sample of psychiatrists and neurologists to assess how resilient they were on a likert scale from 1-5 ("not applicable" to "completely applicable"), and 86% selected the two highest categories. cai et al. 27 compared experienced frontline workers with inexperienced frontline workers, and found that inexperienced workers scored lower on total resilience on the connor-david resilience scale as well as within each of three subscales, and had more mental health symptoms. inexperienced workers were also younger and had less social support available to them. ten studies reported that healthcare workers utilized other resources or had individual strategies to address their own mental health during the pandemic, separate from formal interventions. six studies reported that healthcare workers utilized support from family/friends during the pandemic. "family" was the most common stress coping mechanism utilized by louie et al. kang et al. 40 found slightly higher levels of interest in professional resources. when asked from whom they prefer to receive "psychological care" or "resources", 40% answered psychologists or psychiatrists, 14% answered family or relatives, 15% answered friends or colleagues, 2% answered others, and 30% said they did not need help. the authors found that the preferred sources of psychological resources were related to the level of psychological distress. in a structural equation model that uncovered clusters of healthcare workers with different distress levels (subthreshold, mild, moderate, and severe), those with moderate and severe distress more often preferred to receive care from psychologists or psychiatrists, while those with subthreshold and mild distress more often preferred to seek care from family or relatives. in two studies, participants specified that they had a greater need for personal protective equipment than for psychological help. chung et al. 32 reported this in a survey that allowed healthcare workers to describe their needs and concerns in free text and to request contact with a psychiatric nurse. while 3% requested such contact, nearly half of those who answered the free text question about their psychiatric needs wrote that they needed personal protective equpiment instead, and 20% said they were worried about infection. chen et al.'s 29 study was to understand why uptake of their psychological intervention was so low, and findings were identical to chung et al.'s: "many staff mentioned that they did not need a psychologist, but needed more rest without interruption and enough protective supplies" (p. e15). only one study explored how healthcare workers would be willing to provide mental health services to other healthcare workers: twelve psychiatry residents were re-deployed as frontline workers for one shift in benham et al.'s 24 study. after that shift, none were willing to provide face-to-face mental health services to other healthcare workers, although 75% said they would provide online services. they identified healthcare workers of deceased patients as possible target populations for online services. three qualitative studies assessed as valuable were included. two interconnected themes across all three studies were distress stemming both from concern for infecting family members, and from being aware of family members' concern for the healthcare workers. wu et al. 67 explored reasons for stress during interviews with healthcare workers at a psychiatric hospital. while these healthcare workers were not on the frontline, they felt they were at higher risk of exposure than healthcare workers at a general hospital. their wards were crowded, and several patients were admitted from emergency rooms with aggressive behaviors that made social distancing difficult or that posed direct challenges to healthcare workers' use of personal protective equipment (such as tearing masks). healthcare workers felt unprepared because psychiatric hospitals had no plans in place. at the same time, they also felt that their peers on the frontline were providing more valuable care. an additional source of stress was knowledge of their own risk of infection and transmission to family members, particular to elderly parents in their care, and to children who were at home and whose schoolwork had to additionally be managed. the disruption of the pandemic to nurses' personal lives and career plans was another stressor. sun et al. 65 concern was great enough that several respondents did not tell their family they were working on the frontline, while others did not live at home during this period. as with wu et al.'s 67 nonfrontline workers, these healthcare workers also reported fear and anxiety of a new infectious disease that they felt unprepared to handle on a hospital-level, unprepared to treat on a patientlevel, and from which they were unable to protect themselves. the first week of training and the first week of actual frontline work was characterized by these negative emotions, which were then joinednot necessarily replacedby more positive emotions such as pride at being a frontline nurse, confidence in the hospital's capacity, and recognition by the hospital. yin et al. 72 families, particularly because their families would suffer more financially from needing to be quarantined than they already were suffering under the lockdown; fears of using personal protective equipment incorrectly; and feeling unequipped to handle patients' non-medical needs. healthcare workers reported that stigma suppressed patients' provision of accurate travel and quarantine history. this was an issue they were ill-equipped to help patients address when they returned to the community. healthcare workers also reported that they were stigmatized, because they were potential sources of infection. this systematic review identified 59 heterogeneous studiesincluding three qualitative, fifty quantitative, two narrative reviews, and four other designsthat examined the mental health of between one and two of every five healthcare worker reported anxiety, depression, distress, and/or sleep problems. only one study reported on somatic symptoms such as changes in appetite. our confidence in these broad estimates, assessed using grade, was very low, which leads us to caution that the true prevalence of anxiety, depression, distress, and sleep problems among healthcare workers are likely different than our estimates. at the same time, is also common in interventions for healthcare worker burn-out before the pandemic 83 . the most striking illustration of this was the finding shared by two studies 29 ,32 that healthcare workers said personal protective equipment would benefit their mental health more than professional help. on the other hand, it is possible that healthcare workers could benefit from professional mental health interventions more than they recognize or report, and that under-recognition is related to occupational culture, or fear of stigma or being perceived as weak 84 . while a variety of countries were represented, four of every five participants were chinese, and chinese occupational culture may be a salient mediator of healthcare workers' expressed preferences 85 , although this must be explored further. health's rigorous methodological standards for systematic reviews, such as two researchers screening and assessing eligibility. an additional methodological strength is our utilization of the live map of covid-19 evidence, one of the first reviews to do so (see also two reports 88 ,89 and one diagnostic accuracy study 90 ). by using our map, we quickly identified 871 studies that had already been categorized to our topic and population of interest, without having to search in academic databases and screen again. while not being able to conduct a meta-analysis is unfortunate, it was appropriate not to assume that poorly reported studies were homogenous enough. the principle of homogeneity tends to be overlooked by systematic reviewers eager to produce a summary estimate, but if met, means that all studies included were similar enough that their participants can be considered participants of one large study 91 . the result, however, is that the prevalence data about mental health problems does not provide a summary estimate that can be generalized. other weaknesses are those common to rapid reviews due to time pressure, such as fewer details about the included studies' populations being presented than normally reported. the covid-19 pandemic has resulted in a flood of studies, many of which have been pushed through the peer-review process and published at speeds hitherto unseen (see glasziou 92 for a discussion). it is therefore not surprising that the majority of our included 59 studies were assessed as having a high risk of bias or being of low methodological quality. lack of information on samples or procedures was a common limitation, leading to serious implications to the generalizability and validity of findings. we also call on journals and researchers to balance the need for rapid publication with properly conducted studies, reviews and guidelines 93 . healthcare workers in a variety of fields, positions, and exposure risks are reporting anxiety, depression, distress, and sleep problems during the covid-19 pandemic. causes vary, but for those on the frontline in particular, a lack of opportunity to adequately rest and sleep is likely related to extremely high burdens of work, and a lack of personal protective equipment or training may exacerbate mental health impacts. provision of appropriate personal protective equipment and work rotation schedules to enable adequate rest in the face of long-lasting disasters such as the covid-19 pandemic seem paramount. over time, many more healthcare workers may struggle with mental health and 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during the covid-19 pandemic, now more than ever and no matter what key: cord-333187-8p61xten authors: norr, aaron m.; katz, andrea c.; nguyen, janelle l.; lehavot, keren; schmidt, norman b.; reger, greg m. title: pilot trial of a transdiagnostic computerized anxiety sensitivity intervention among va primary care patients date: 2020-08-17 journal: psychiatry res doi: 10.1016/j.psychres.2020.113394 sha: doc_id: 333187 cord_uid: 8p61xten people in need of mental health treatment do not access care at high rates or in a timely manner, inclusive of veterans at department of veteran's affairs (va) medical centers. barriers to care have been identified, and one potential solution is the use of technology-based interventions within primary care. this study evaluated the cognitive anxiety sensitivity treatment (cast), a previously developed computerized treatment that has shown efficacy in community samples for mental health symptoms including: anxiety, depression, post-traumatic stress, and suicidal ideation. va primary care patients with elevated anxiety sensitivity (n = 25) were recruited to participate in a mixed-method open pilot to examine acceptability, usability, and preliminary effectiveness in a va primary care setting. participants completed an initial visit, that included the intervention, and a one-month follow-up. veterans found cast to be generally acceptable, with strong usability ratings. qualitative analyses identified areas of strength and areas for improvement for use with va primary care veterans. repeated measures ancovas revealed significant effects for symptoms of anxiety, depression, traumatic-stress, and suicidal ideation. cast could potentially have a large public health impact if deployed across va medical centers as a first-step intervention for a range of mental health presenting concerns. people in need of mental health treatment typically do not access care at high rates or in a timely manner. nationally representative, population-based research suggests that only 41% of those with mental health disorders access treatment the year prior and only 33% receive minimally adequate treatment, if any treatment at all (wang et al., 2005) . delays from mental health disorder onset to treatment initiation can span years, with the average delay reaching a decade in the u.s. (wang et al., 2004) . problems accessing mental health care persist for some in the department of veterans affairs (va; keller & tuerk, 2016; maguen et al., 2012) . for example, thirty-five percent of operation enduring freedom/operation iraqi freedom (oef/oif) veterans at the va meet criteria for at least one mental health diagnosis. even with improvements in access to treatments for some mental health disorders (karlin & cross, 2014; goldberg et al., 2019) many veterans never access mental health care, or do not received adequate doses of mental health care, despite the presence of impairing mental health symptoms (brown & jones, 2016; seal et al., 2010; teich et al., 2016) . veteran barriers to care have been specified (e.g., bovin et al., 2019; possemato et al., 2018; tanielian & jaycox, 2008) , including concerns about stigma, medication side effects, confidentiality, and logistical barriers such as veteran schedule and access. to address these issues, and consistent with national healthcare priorities (institute of medicine, 2014), va has aggressively pursued the embedding of mental health specialists in primary care (department of pilot trial of cast among veterans veterans affairs, 2015) . integrated mental health allows for the treatment of mild to moderate psychiatric disorders and behavioral health problems in primary care, with on-going symptom assessment and a stepped-care approach to referrals to additional mental health interventions. in stepped-care approaches, patients are started with the least intensive treatment and are offered more intensive treatments as needed (bower & gilbody, 2005) . this approach is thought to have the potential to increase both treatment engagement and efficiency in proving mental health care. indeed, embedding mental health specialists in primary care and employing a stepped-care approach has been shown to improve access to mental health services (leung et al., 2019; leung et al., 2018) . technology-based interventions can play an important role in integrated mental health stepped-care approaches to treatment (e.g., espie, 2009; green & iverson, 2009 ), as they address some barriers to care by drawing on convenience, the ability to reach individuals in remote locations and on the patient's schedule, and the elimination of face-to-face meetings with clinicians, thereby reducing stigma associated with seeing a mental health professional. one highly promising technology-based intervention for mental health symptoms is the cognitive anxiety sensitivity treatment (cast; schmidt et al., 2014) . cast specifically targets anxiety sensitivity, or a fear of anxiety and related sensations, which has been shown to be a transdiagnostic risk factor that contributes to the development and maintenance of a variety of mental health symptoms, including anxiety, depression, post-traumatic stress, and suicidal ideation (capron et al., 2013; marshall et al., 2010; naragon-gainey, 2010) . cast is a fully computerized, 45-minute intervention that comprises education about the nature of anxiety symptoms and a guided interoceptive exposure exercise (i.e., voluntary hyperventilation), which pilot trial of cast among veterans is a well-established, highly effective intervention for reducing fearful responding to anxiety sensations (schmidt & trakowski,2004) . cast has demonstrated efficacy in reducing symptoms of ptsd, anxiety, depression, and suicidal ideation in multiple randomized controlled trials (schmidt et al., 2014 (schmidt et al., , 2017 short et al., 2017a) , but limited research exists among veterans. a secondary analysis (short et al., 2017b) of cast users from a previous randomized clinical trial (schmidt et al., 2014) found that the sub-set 16 community-dwelling veterans in the sample reported moderate or higher usability and applicability, and veterans' acceptability ratings were modestly higher than non-veteran participants. another study evaluated cast among 16 veterans engaged in a va intensive outpatient treatment for opioid use disorder. this study reported adequate acceptability/usability and a medium effect size for reductions in anxiety sensitivity. small-to-medium effect size reductions were found for depression, anxiety, and stress. notably, neither of these prior studies examined acceptability of cast among veterans engaged with primary care at va, and neither included qualitative methods to determine areas for improvement for use with veterans. veterans in primary care present with a broad range of needs, broad range of symptoms (seal et al., 2007) , and are arguably an ideal population and setting to deploy a first-step intervention, a single-session, transdiagnostic intervention (bower & gilbody, 2005) such as cast due to the potential of eliminating the potential barriers associated with referral to specially mental health. examining acceptability, usability, and preliminary efficacy of cast, and gathering critical qualitative feedback to determine potential areas for improvement is an essential next step towards successfully deploying this intervention, and other similar interventions, within a large healthcare system like va. this study evaluated the use of the cast program in va primary care patients through an open, pilot trial. the primary outcomes were traumatic stress, anxiety, and depressive symptoms. qualitative feedback was collected to assess acceptability and usability of the intervention as well as to determine potential areas of improvement for using cast with veterans within a primary care setting. study aims were to: (1) collect user feedback from veterans regarding the acceptability/usability of cast and potential areas of improvement for use with veterans, and; (2) investigate the preliminary efficacy of cast in reducing mental health symptoms (anxiety, depression, and ptsd) among veterans enrolled in va primary care. us military veterans (n = 25) were recruited from a large va medical center via referrals from healthcare providers, flyers/brochures, and staffed waiting area tables in the primary care clinic and outpatient mental health clinic. veterans were invited to participate in a study examining a "computerized treatment for stress and anxiety." veterans were eligible if they were (1) enrolled in primary care at the va facility and (2) scored at least 1 sd above the community mean on the anxiety sensitivity index-3 (asi-3) cognitive subscale (score of > 7; taylor et al., 2007) . exclusionary criteria included: (1) age greater than 65, (2) women who are pregnant, (3) history of stroke, seizure, irregular heartbeat, or heart failure, (4) uncontrolled chronic obstructive pulmonary disease (copd), emphysema, or asthma. given the study team's inability to provide medical clearance for participation, exclusionary criteria were selected in consultation with a physician to ensure no negative side effects of the interoceptive exposure exercise (voluntary hyperventilation) among individuals with these characteristics. participants were on average 51.44 years old (sd = 9.49) and the majority identified as male (84%) and caucasian (72%). full sample demographics can be found in table 1. -3 (asi-3) . the asi-3 is an 18-item questionnaire used to assess fear of anxiety-related sensations and has been validated in community and clinical samples (taylor et al., 2007) . participants rate the degree to which they agree with each item on a 5-point scale ranging from "very little" to "very much". higher scores indicate a greater fear of anxiety-related sensations. the asi-3 was administered at baseline, post-intervention, and at 1-month follow-up. in the current sample the asi-3 demonstrated excellent internal consistency at baseline (α = .93). the gad-7 (spitzer et al., 2006 ) is a 7item questionnaire designed to assess anxiety symptoms. the gad-7 has been widely validated and is commonly used clinically in the va to assess for symptoms of anxiety. participants rate how often they have been bothered by specific symptoms on a 4-point scale ranging from "not at all" to "nearly every day". the gad-7 was administered at baseline and at the 1-month followup. in the current sample the gad-7 demonstrated good internal consistency at baseline (α = .87). the phq-9 (spitzer et al., 1999 ) is a 9item questionnaire designed to assess symptoms of depression. the phq-9 has been widely validated and is used in routine practice in the va to assess for symptoms of depression. participants rate how often they have been bothered by specific symptoms on a 4-point scale ranging from "not at all" to "nearly every day". the phq-9 was administered at baseline and at the 1-month follow-up. consistent with many previous studies (e.g., louzon et al., 2016; pilot trial of cast among veterans al., 2018), item 9 ("thoughts that you would be better off dead, or of hurting yourself") was used as an efficient means to examine suicidal ideation. in the current sample the phq-9 demonstrated excellent internal consistency at baseline (α = .91). the pcl-5 (weathers et al., 2013 ) is a 20item questionnaire designed to assess the symptoms of ptsd. the pcl-5 has been widely validated and is commonly used clinically in the va to assess for symptoms of ptsd. participants rate how much they have been bothered by specific symptoms on a 5-point scale ranging from "not at all" to "extremely". the pcl-5 was administered at baseline and at the 1month follow-up. in the current sample the pcl-5 demonstrated excellent internal consistency at baseline (α = .93). the sus is a widely used, 10-item self-report questionnaire that assesses the usability of technology systems (brooke, 1996) . participants rate their experience with the usability of the computer program on a 5-point scale ranging from "strongly disagree" to "strongly agree". the sus was administered post-intervention and demonstrated good internal consistency (α = .83). the aq is an 8-item questionnaire designed to assesses the subjects' perceived acceptability of, and engagement with, the cast program across various domains and the items have been used in previous studies examining the cast program (norr et al., 2017a; raines et al., 2020; short et al., 2017b) . the aq was administered post-intervention. two qualitative interviews were conducted (at post-intervention and 1-month follow-up) to assess participants' user experiences with the cast program. the questions were designed by study investigators to identify areas for improvement in future iterations of the program. responses were summarized, transcribing word for word when possible, by a study research coordinator during the interview. for this analysis, only data from the interview administered post-intervention was included. the specific questions were: "what did you like about the program?", "what did you not like about the program?", and "what are three ways this program can be improved for use specifically with veterans?". a pre-enrollment study screen to determine eligibility was conducted in person or over the phone by a study research coordinator and lasted approximately 2-5 minutes including completion (written or verbal) of the asi-3 cognitive subscale. volunteers deemed initially eligible were then scheduled for the first study visit. at the initial study visit, participants were provided with an overview of the study and completed written informed consent. after informed consent, participants completed baseline self-report measures that assessed demographics, current and past mental health treatment, as well as symptoms of anxiety, depression, and ptsd. once baseline measures were completed, participants were instructed on how to navigate the cast program on a laptop computer. after completing cast (45 minutes), participants completed post-treatment questionnaires to assess changes in anxiety sensitivity levels from baseline, along with rating the acceptability/usability of the cast program in a va setting. following all questionnaires, participants completed a qualitative interview with a study pilot trial of cast among veterans coordinator trained in rapid qualitative inquiry (e.g., reger et al., 2017 ) by an experienced doctoral-level qualitative researcher. the entire in-person visit lasted approximately 2 hours. at the one-month follow-up visit, participants completed a questionnaire packet to measure symptom change and another qualitative interview to give participants the opportunity to provide additional feedback about the cast intervention. this entire in-person visit lasted approximately 30-45 minutes. program consists of 50 slides that contain video animation and audio narration throughout, as well as interactive features, such as brief-intermittent quizzes to promote comprehension. participants start with psychoeducation on anxiety-related sensations (e.g., elevated heart rate, difficulty concentrating) and are provided corrective information aimed at dispelling myths commonly held by individuals with high anxiety sensitivity. participants are then shown how to complete interoceptive exposures through a guided video and are told that these exposures can help correct their conditioned fear to anxiety-related sensations. participants then complete ten, 60-second guided hyperventilation trials and are asked to rate after each trial the intensity of the sensations experienced and their subjective distress. after completing the hyperventilation trials, the participant's responses are graphed by the program to demonstrate any changes over the course of the trials. pilot trial of cast among veterans to examine changes in as from baseline to post (n = 25) paired samples t-tests were utilized. changes in as and symptoms over the period from baseline to follow-up (n = 21), were examined with repeated measures ancovas (baseline and 1-month follow-up time points). the number of individual and group mental health appointments (assessed via medical record review) during the study period (baseline to 1-month follow-up) were included as covariates to control for the effect of mental health appointment attendance over the course of the study. only participants who completed both measurement points for the test of interest were included. matrix analysis was used to evaluate the qualitative interview data, which provides a visual template of the systematic coding and categorization process of the pattern of responses collected from participants (averill, 2002) . first, two subject matter experts (amn and gmr) reviewed all interview responses and independently created proposed categories for the matrix. these proposed categories were then reconciled with one another, and the final coding categories were placed along the top of the matrix. next, two research team members (ack & jln) independently coded responses vertically under the corresponding category to display trends and frequency of the responses per category splitting by strengths and weaknesses. all disagreements were reconciled through discussion between the coders. item-level results from the aq can be seen in table 2 . the majority of participants rated cast as at least "moderately easy" to understand (88%), "moderately easy" or "easy" to follow (88%), at least "moderately helpful" (88%), at least "somewhat engaging" (88%), "somewhat interesting" or "very interesting" (96%), and at least "somewhat applicable" to daily life (84%). the majority of participants also found cast to be "somewhat applicable" or "very applicable" to stressors during military service (72%). eighty-eight percent of participants reported that they were "somewhat likely" or "very likely" to use the information and techniques learned. sus scores (m = 83.00, sd = 13.75) demonstrated good-to-excellent usability and were higher than average sus scores found through meta-analytic work (m = 70; bangor et al., 2008) . qualitative data indicated that user reactions to the cast intervention largely fell into four domains: usability of the program, quality of content presented, impact of the intervention on the participant, and its applicability to military and veteran populations. participants generally highlighted both strengths and weaknesses within each of these domains (see table 3 ). when discussing the program's usability and design, participants appreciated that the cast program was straightforward, easy to use, and easy to understand. others appreciated the auditory component of the program, commenting on the narrator's voice, tone, and pace while delivering the information. veterans also noted cast's overall structure helped with usabilitythat the layout, order, visual aids, and quizzes solidified their learning. veterans highlighted three areas of weakness in cast's usability. first, they suggested that breaks be built into the intervention so that information is easier to absorb. second, others took issue with the computer-only format and voiced a desire to discuss the ideas presented in a larger group setting. finally, veterans noted some technical difficulties that interfered with the program, such as long buffering time slowing the intervention down, distracting flashing between slides, and difficulty viewing the information against a dark background. when commenting about the content of cast, many study participants appreciated the education on myths and facts about stress and anxiety and the physiological components of stress, noting they learned something new. when considering the weaknesses of the content, several veterans highlighted their desire for more information, such as about how stress manifests in different psychiatric diagnoses, specific information about post-traumatic stress disorder, and how to apply these skills to stress in the moment. in addition, some veterans objected to the myths and facts element of the education, as the "facts" presented did not fit their worldviews. participants had mixed views on the breathing exercises. though many highlighted the practical exercises as strengths of the intervention which allowed them to solidify their learning and practice a useful skill, others had difficulty with them and found them distressing. the fewest responses fell into the impact and outcome domain. regarding strengths within this domain, several participants were pleased with the observed improvements in their stress levels after completing cast, and others commented on the lasting knowledge they gained through participation. one veteran voiced disappointment that their stress symptoms did not improve during the intervention. finally, when considering cast's relevance to military and veteran populations, many participants found the program quite relatable to veterans' issues. however, others thought that the inclusion of more combat-and military-specific examples, more visuals of women veterans (including the option for a female narrator), and information about ptsd specifically would help the program be more relevant. veterans also noted how useful this program might be among veterans, as many comments included a call for additional outreach to make it more widely available, including delivery in a remote format that would not require presenting to the medical center. paired samples t-test revealed medium effects for baseline to post cast change in asi-3 total (δm = 7.60, δsd = 11.25; t (24) = 3.38. p = .002; d = .68), asi-3 physical (δm = 2.44, δsd repeated measures ancovas, controlling for mental health appointment attendance between study visits, revealed medium-to-large effects on asi-3, gad-7, phq-5, pcl-5 and suicidal ideation (phq-9 item 9) from baseline to 1-month follow-up (see table 4 for full results). the purpose of the current study was to examine the acceptability, usability, and preliminary effectiveness of a transdiagnostic computerized intervention for anxiety sensitivity focused on va primary care patients. results from the acceptability questionnaire revealed the majority of participants found the intervention acceptable across eight different domains, and usability scores (sus) were higher than meta-analytic averages (bangor et al., 2008) . these results are consistent with prior work examining acceptability of cast among veterans in an academic setting (short et al., 2017b) and among veterans in a va opioid use disorder intensive outpatient program (raines et al., 2020) . results from the qualitative analysis fleshed out these results and provided rich data on several areas of strength as well as areas for potential improvement. veterans appreciated the pilot trial of cast among veterans information being presented both visually and auditorily, citing this bimodal presentation as helpful for engagement and for understanding the content. further, they appreciated that the information was presented in a straightforward manner while focusing on specific knowledge they can carry forward with them to better understand their experience of anxiety and stress symptoms. some veterans even requested more information on anxiety and stress symptoms, highlighting the importance of the educational component. as psychoeducation has been shown to be effective across many different treatment settings and outcomes (e.g., norr et al, 2017b; perry et al., 2017; powell et al., 2019) , finding ways to increase accessibility to psychoeducational content could be one method to further engage veterans in primary care in mental health treatment. veterans expressed interest in having more cast content examples that are specific to veterans/military service and requested opportunities to discuss the content with other veterans. these responses highlight the importance of military culture and of peers in providing competent care to veterans and service members (meyer & wynn, 2018) . veterans also expressed optimism with employing an outreach program to get this intervention into the hands of veterans who may be more apprehensive about engaging with traditional mental health services. this feedback encourages continued efforts by the va and the department of defense to create and disseminate non-traditional treatment options including internet-based and mobile health applications (gould et al., 2019) . while the current study examined completion of cast at an in-person, research appointment at a va medical center, prior work has suggested effectiveness of cast when delivered remotely via the internet (norr et al., 2017a) . such an approach could be a useful way to engage veterans who are not willing to attend in-person appointments, and pilot trial of cast among veterans could be particularly advantageous when in-person care is not possible, for example during a pandemic as seen with covid-19. regarding the intervention's efficacy, the current study saw significant, medium-sized decreases in as between baseline and posttest (d = .68) and baseline to 1-month follow-up (d = .61). these effect sizes are commensurate with studies examining cast among undergraduate rct; d = .81 ) and community participants (schmidt et al., 2014; rct; d = .57 ) in an academic setting as well as among veterans in a va opioid use disorder intensive outpatient program (raines et al., 2020 ; open pilot; glass's δpre of 0.61). results also revealed significant reductions, with large effects, for anxiety symptoms, depressive symptoms, ptsd symptoms, and suicidal ideation. the demonstrated reductions across a range of psychological symptoms is consistent with prior randomized controlled trials of cast among community participants (schmidt et al., 2014; schmidt et al., 2017) . these results suggest cast program could be efficacious among va primary care patients, and therefore has the potential to be a highly efficient and scalable treatment in a va primary care setting with regard to both time investment from patients and resource investment from the va system. as a healthcare system, the va faces unique challenges associated with enacting mental healthcare among a population that can be challenging to engage (seal et al., 2010) . results from the current study suggest that the single-session cast program could be an acceptable, effective, and efficient way to provide evidence-based mental health care to va primary care patients. the results from the current study are promising given many veterans express negative beliefs about mental health treatment generally (fox et al., 2015) and identify barriers to receiving mental healthcare within a va setting (cheney et al., 2018) , demonstrating the need for novel treatment delivery methods. thus, cast would help address these national priorities pilot trial of cast among veterans to integrate mental health care into medical settings (institute of medicine, 2014) to overcome some of these barriers to care as it can be deployed without trained mental health providers. similarly, cast could be offered as a first step within a stepped-care model (bower & gilbody, 2005) with veterans graduated to higher levels of care as indicated. indeed some veterans in the current study commented they wanted follow-up in a group or individual setting, while others did not. thus, having a non-traditional treatment option, such as cast, be offered in a primary care setting could help engage veterans who would otherwise not engage in mental health care, or who might further delay accessing care due to stigma about mental health treatment. the current study is not without limitations. first, all veterans who participated in the current study were either currently (56%) or previously engaged in psychotherapy (40%). thus, though all participants were va primary care patients, it is possible that the results would be different for a sample of va primary care patients who were naïve to mental health treatment. however, these patients likely offer an important perspective as they are aware of other mental health treatment experiences. similarly, the results of the current study suggest that the cast intervention can confer benefit even for those who have already received more traditional mental health care. second, the single group design of the current study limits the ability to draw conclusions about the causal nature of the observed reductions in symptoms. importantly, we controlled for the number of mental health (individual and group) appointments attended over the course of the study to ensure results were not simple associated with mental health appointment attendance. third, the current study utilized a single item measure of suicidal ideation. though a more comprehensive measure of suicide risk may provide a more nuanced perspective, research in a large sample (louzon et al., 2016; n= 447,245) of veterans found that a single item measure of si significantly predicted suicide mortality (hr = 1.47), supporting the pilot trial of cast among veterans utility of measuring si in this fashion. forth, for the qualitative portion of the study we relied on interviewer notes to capture response themes. it is possible this method could have resulted in missing information that would have been captured with audio recorded transcripts. finally, though cast was completed on the computer, all sessions were completed at the va facility in the presence of a research coordinator. it is possible that completing this intervention remotely would yield a different treatment experience and results. prior work suggests that completing cast remotely confers benefit (norr et al., 2017a) , however, future research should investigate this among a va population. important areas of future research include examining the efficacy of cast for mental health treatment naïve veterans, utility of employing cast within a stepped care model embedded in primary care, and efficacy of cast when delivered remotely to va primary care patients to determine whether an in-office visit is needed. despite these limitations, the strong evidence of efficacy among community participants from prior randomized controlled trials coupled with the results from the current study further promote potential of cast, and similar treatments, to reach veterans who otherwise would not receive care. veterans found this treatment experience to be highly acceptable and reported benefit with regard to symptoms of anxiety, depression, ptsd, and suicidal ideation. involving veterans in the collaborative development of these types of interventions is consistent with best practices in human centered design and is critical to achieving products veterans find to be culturally competent. the results for the current study point to potential areas of improvement for cast such as including more military relevant example and having the option for further engagement with this material via a group setting following the completion of cast. additional research is needed to explore feedback from mental health treatment naïve veterans to examine the effects of cast on future engagement in mental health care, and to evaluate the program pilot trial of cast among veterans delivered via a remote format. however, given the low cost of scaling and disseminating cast (norr et al., 2017a) , the results of the current study suggest the possibility of cast having a large public health impact across va medical centers nationwide as a first-step intervention for a range of mental health presenting concerns. weakness "break up the information, not all in one session. allow for discussion with others, put it into a group session." "dark theme should change to a lighter theme" "recognizing the stress is one thing, education about how to handle the stress would be helpful." "too absolute in the 'facts' presented in the programdoesn't apply to all people." "ten times for breathing exercises was stressful" "did not improve stress symptoms" "more examples that relate to veterans specifically rather than civilians (different types of stress)." "adding more material related to combat, questions and examples. . . more female veterans. female specific program would be helpful." pilot trial of cast among veterans table 4 . changes in clinical variables from baseline to 1-month follow-up note. asi-3 = anxiety sensitivity index -3; gad-7 = generalized anxiety disorder -7; phq-9 = patient health questionnaire -9; pcl-5 = ptsd checklist for dsm-5. matrix analysis as a complementary analytic strategy in qualitative inquiry an empirical evaluation of the system usability scale veterans' experiences initiating va-based mental health care stepped care in psychological therapies: access, effectiveness and efficiency: narrative literature review sus-a quick and dirty usability scale. usability evaluation in industry mental health and medical health disparities in 5135 transgender veterans receiving healthcare in the veterans health administration: a casecontrol study veteran-centered barriers to va mental healthcare services use vha handbook 1160.01: uniform mental health services in va medical centers and clinics stepped care": a health technology solution for delivering cognitive behavioral therapy as a first line insomnia treatment attitudes about the va health care setting, mental illness, and mental health treatment and their relationship with va mental health service use among female and male oef/oif veterans mental health treatment delay: a comparison among civilians and veterans of different service eras veterans affairs and the department of defense mental health apps: a systematic literature review computerized cognitive-behavioral therapy in a stepped care model of treatment mental disorders and mental health treatment among us department of veterans affairs outpatients: the veterans health study board on the health of select populations, & committee on the assessment of ongoing efforts in the treatment of posttraumatic stress disorder from the laboratory to the therapy room: national dissemination and implementation of evidence-based psychotherapies in the u.s. department of veterans affairs health care system evidence-based psychotherapy (ebp) non-initiation among veterans offered an ebp for posttraumatic stress disorder changing patterns of mental health care use: the role of integrated mental health services in veterans affairs primary care veterans health administration investments in primary care and mental health integration improved care access does suicidal ideation as measured by the phq-9 predict suicide among va patients? time to treatment among veterans of conflicts in iraq and afghanistan with psychiatric diagnoses anxiety sensitivity and ptsd symptom severity are reciprocally related: evidence from a longitudinal study of physical trauma survivors the importance of us military cultural competence meta-analysis of the relations of anxiety sensitivity to the depressive and anxiety disorders evaluating the unique contribution of intolerance of uncertainty relative to other cognitive vulnerability factors in anxiety psychopathology online dissemination of the cognitive anxiety sensitivity treatment (cast) using craigslist: a pilot study is computerized psychoeducation sufficient to reduce anxiety sensitivity in an at-risk sample?: a randomized trial effects of prolonged exposure and virtual reality exposure on suicidal ideation in active duty soldiers: an examination of potential mechanisms development of a guided internet-based psycho-education intervention using cognitive behavioral therapy and selfmanagement for individuals with chronic pain facilitators and barriers to seeking mental health care among primary care veterans with posttraumatic stress disorder stress and coping in social service providers after superstorm sandy: an examination of a postdisaster psychoeducational intervention a computerized anxiety sensitivity intervention for opioid use disorders: a pilot investigation among veterans barriers and facilitators to mobile application use during ptsd treatment: clinician adoption of pe coach interoceptive assessment and exposure in panic disorder: a descriptive study randomized clinical trial evaluating the efficacy of a brief intervention targeting anxiety sensitivity cognitive concerns a randomized clinical trial targeting anxiety sensitivity for patients with suicidal ideation bringing the war back home: mental health disorders among 103 788 us veterans returning from iraq and afghanistan seen at department of veterans affairs facilities va mental health services utilization in iraq and afghanistan veterans in the first year of receiving new mental health diagnoses a randomized clinical trial examining the effects of an anxiety sensitivity intervention on insomnia symptoms: replication and extension acceptability of a brief computerized intervention targeting anxiety sensitivity validation and utility of a self-report version of prime-md: the phq primary care study a brief measure for assessing generalized anxiety disorder: the gad-7 invisible wounds of war: psychological and cognitive injuries, their consequences, and services to assist recovery robust dimensions of anxiety sensitivity: development and initial validation of the anxiety sensitivity index-3 utilization of mental health service by veterans living in rural areas delays in initial treatment contact after first onset of a mental disorder twelvemonth use of mental health services in the united states the ptsd checklist for dsm-5 (pcl-5) contributions: aaron norr designed the study/analyses and contributed to writing all parts of the, methods, results, and discussion sections. andrea katz contributed to the qualitative analyses and contributed to writing the results section. janelle nguyen collected data, contributed to the qualitative analyses, and contributed to the writing of the methods section. keren lehavot contributed to the design of the study and provided feedback and edits to the manuscript. norman schmidt created the cast intervention and provided feedback and edits to the manuscript. greg reger provided crucial feedback and edits throughout study design, analysis, and writing of the manuscript. all of the authors have agreed to the author order and to submission of the manuscript in this form. key: cord-344069-f32itts9 authors: glowacz, f.; schmits, e. title: uncertainty and psychological distress during lockdown during the covid-19 pandemic: the young adults most at risk date: 2020-09-25 journal: psychiatry res doi: 10.1016/j.psychres.2020.113486 sha: doc_id: 344069 cord_uid: f32itts9 to control the covid-19 pandemic, governments have implemented restrictions. this study evaluates psychological distress related to the crisis and identifies predictive factors of anxiety/depression according to age. 2,871 adults were recruited through an online questionnaire during the lockdown. three subsamples were identified: 18–30; 30–50; > 50 years. the population suffers from anxiety and depression. youth reported lower levels of living space, occupational activity, social contact and alcohol use, but higher anxiety, depression and uncertainty than older participants. this psychological distress can be explained by lockdown conditions (differently according to age) and by intolerance to uncertainty. also, youth's alcohol intake has decreased. deconfinement strategies have been discussed. ethics approval statement: all respondents agreed to participate in the study, which was approved by the ethics committee at liege university. on march 11, 2020, the who declared the covid-19 outbreak as a pandemic as the virus spread worldwide. governments across the world have imposed restrictive measures, such as lockdowns, social distancing and voluntary self-isolation (huang, & zhao, 2020; hossain et al., 2020; sharma et al., 2020; brooks and al., 2020) , preventing the transmission. these measures have disrupted people's lives and jobs, and have implications for health and wellbeing (liu et al., 2020; cao et al., 2020) . studies have reported high levels of depressive and anxiety symptoms, poor sleep quality, especially in young (huang & zhao, 2020) . predictors of distress related to containment may vary across countries (jahanshahi, et al. 2020) . for belgium, france and quebec, lockdowns were declared on mid-march and progressive deconfinement was organized from may 4 onwards. as psychological risks and impacts differed across age and countries, it is important to understand what has determined psychological distress in confined people by age category in order to have an idea of the issues that may appear during deconfinement. uncertainty remains a component of any pandemic crisis, with the serious threat the covid-19 epidemic poses to people's physical health and lives, as well as the impossibility of knowing in advance the duration of containment, the real risk of being contaminated, the symptomatic manifestations of the virus and the consequences at personal, economic and societal levels. intolerance of uncertainty may be a risk factor for depression and anxiety (freeston et al., 1994; carleton et al., 2012) . population has to cope with confinement, impacting people's psychological state and substance use behaviors. digital technologies and internet-based medias and applications (such as zoom, skype, whatsapp and facetime) could bridge social distance and allow for the maintenance of social interactions (merchant et al., 2020; galea et al., 2020) . this would be a protective factor for distress. also, the covid-19 pandemic is likely to increase substance use. stress is a prominent risk factor for the onset and maintenance of alcohol misuse but the potential public health effects of long-term isolation on alcohol use are unknown (clay & parker, 2020) . the main purpose of this study is to measure the psychological distress related to the covid-19 crisis and public health measures associated with its containment, and to provide mental health intervention policies to cope with this challenge. this study proposes to assess the association between the proximity to contamination, lockdown conditions, alcohol use and intolerance to uncertainty, and anxiety and depressive symptoms separately among youth, middle-aged and older populations. 2,871 adults (79% women) were recruited in the general population through an online selfreport questionnaire. participants were aged between 18 and 85 years (m = 33.67, sd = 15.35). three age groups were identified: 18-30 years (n=1,479, 51.5% of the sample), 30-50 years (n=885, 30.8%) and 50 years and more (n=507, 17.6%). 84.5% of participants live in belgium, 14.8% in another french-speaking country (mainly france and canada). data were obtained through an online self-report questionnaire (approved by the ethics committee of the faculty of psychology of the university of liège) completed during the lockdown (from april 17 to may 1, 2020). sociodemographic data and lockdown conditions were assessed: the living environment (surface area of the accommodation, the availability of a terrace/garden), professional situation (student, working from home, usual workplace, no work), loss of financial income (yes/no). occupational activity was estimated through 11 items on a 4-points likert scale evaluating several daily activities such as reading or watching tv (α=.51; m=24.31; sd=4.39; min=11; max=44). the frequency of social contact was assessed through 7 items on a 4-points likert scale evaluating contact with friends, family, colleagues and so on through digital media (α=.54; m=16.17; sd=3.66; min=7; max=28). the primary (oneself) and the secondary (a close person) coronavirus contaminations were specified with three modalities (not infected, infected but not tested, tested positive for the coronavirus) and a score of proximity to contamination was determined (m=.92; sd=1.63; min=0; max=8). validated measures were adapted to the context of the covid-19 crisis and the related-lockdown. alcohol use was assessed through an adapted audit-c questionnaire (bush et al., 1998) (m=2.5; sd=1.18; min=1; max=5) . changes in alcohol use was assessed: decrease, stability and increase. anxiety and depression were evaluated by the the hospital anxiety and depression scale (had, zigmond & snaith, 1983) with seven items for anxiety (α=.81; m=7.15; sd=4.14; min=0; max=21) and seven for depression (α=.67; m=7.88; sd=3.60; min=0; max=21). cut-off points are 8 and 11 (bjelland et al., 2002) . two items of the intolerance of uncertainty scale (freeston et al., 1994) have been included (α=.74; m=6.85; sd=2.01; min=2; max=10). a question evaluating if the person had consulted a psychologist during the lockdown (yes/no) was also added. spss 26 software was used to, first, perform descriptive statistics, consistency reliability and kruskal-wallis one-way analysis of variance (age group comparison). second, to predict anxiety and depression, two distinct models were tested (multiple regressions), separately for three subsamples (18-30 years; 30-50 years and >50 years). statistical significance was set at p < 0.05. descriptive statistics are shown in table 1 . with the exception of gender, the three age groups' profiles significantly differ from each other. participants aged 18-30 years reported significantly lower levels of living environment, occupational activity, social contacts, frequency and quantity of alcohol use, but higher levels of anxiety, depression and uncertainty than older participants. insert table 1 here after controlling for gender (p>.05), higher rates of anxiety have been reported among (1) young with higher levels of proximity to contamination (β=.05, p=.01), social contact through digital media (β=.07, p=.001) and intolerance to uncertainty (β=.53, p<.001), and less frequent use of alcohol (β=-.05, p=.02) (environment and occupation are not significant); (2) middle-aged people with higher levels of social contact through digital media (β=.11, p=.001) and intolerance to uncertainty (β=.41, p<.001) (proximity to contamination, environment, occupation and alcohol use are not significant); (3) older people with higher levels of occupational activity (β=.08, p=.03) and intolerance of uncertainty (β=.53, p<.001), and a lower level of living environment (β=-.08, p=.04) (proximity to contamination, social contact and alcohol use are not significant). after controlling for gender (p>.05), results also shown higher rates of depression among (1) young with higher levels of intolerance to uncertainty (β=.37, p<.001), and lower levels of living environment (β=-.07, p=.004), occupational activity (β=-.12, p<.001) and social contact through digital media (β=-.07, p=.004) (proximity to contamination and alcohol use are not significant); (2) middle-aged people with higher levels of intolerance to uncertainty (β=.35, p<.001), and a lower level of occupational activity (β=-.16, p<.001) (proximity to contamination, environment, social contact and alcohol use are not significant); (3) older people with higher levels of intolerance to uncertainty (β=.39, p<.001), and a lower level of living environment (β=-.13, p=.001) and social contact through digital media (β=-.10, p=.01) (proximity to contamination, occupation and alcohol use are not significant). note that beta coefficient are relatively low, expected for intolerance to uncertainty. a considerable percentage of the population suffers from anxiety and depressive symptoms related to the covid-19 lockdown and it can be explained by an intolerance of uncertainty, whatever the age of the people. this uncertainty in itself can increase the level of psychosocial morbidity (freeston et al., 1994; carleton et al., 2012; freeston et al., 2020; sim & chua, 2004; sankar et al., 2017) . reducing uncertainty is necessary to reduce anxiety and depressive symptoms. uncertainty tends to increase fear (mertens et al., 2020; hancock and mattick, 2020) . effective health communication could mitigate uncertainty by providing the general public with clear information and sticking to the facts as much as possible (van der bles et al., 2020); consistent and specific information by avoiding fear-based communication and instructions (finset et al., 2020) . the communication should rather be empathic, by acknowledge the impact of the situation for individuals' emotions and lives (shen, 2010; finset et al., 2020) . during the deconfinement process, communicating clear, unambiguous messages about social behaviours, notably, in relation to the wearing of masks, face to face and touch contact, the conditions for frequenting bars, will also help reduce uncertainty. young people are the most impacted by the covid-19 lockdown (huang & zhao, 2020) . proximity to contamination (only for young people), an overload of contact through social networks and a high intolerance to uncertainty increases anxiety in this population. half of the present young subsample is made up of students who are consumed by major uncertainties regarding their future and educational perspectives. young people can develop creative solutions and new skills to deal with the pandemic, but they are nevertheless the most psychologically troubled. contact through digital media is anxiety-provoking for them and cannot replace face-to-face contact. youth were the least to seek psychological help via visio-consultation. distance education and examinations could increase their level of uncertainty and stress, either because these involve new teaching and assessment modalities as yet unknown to them, or because distance supervision, communication and monitoring by teachers has not been sufficiently clear, structured and reassuring. it is important to propose clear guidelines for teachers to help them communicate with students, to offer access to infrastructure that will be conducive to their well-being, such free psychological consultations, and the promotion of access to sports and cultural centers. the government and schools should collaborate to provide high-quality, timely crisis-oriented psychological services to college students (cao and colleagues, 2020) . also, new studies are needed for help to inform student-centered support programs and mitigate the long-term negative implications (gubric et al., 2020 ; van daele et al., 2020) , also for employed or unemployed youth. few studies on the consumption of alcohol in the general population during confinement have been published (clay & parker, 2020) . young people have drunk alcohol less often and in smaller quantities, but with an anxiolytic effect. the symptoms of older people are not affected by alcohol use. alcohol is not a common mean of combating anxiety/depression in the whole population in a locked-up situation. although half the population did not change their alcohol consumption habits during the lockdown, a larger percentage of young have decreased their alcohol consumption than increased it. but a larger percentage of middle-aged and older people have seen an increase in their alcohol consumption habits. alcohol use among young should mainly take place in social contexts, whereas older people increase their alcohol use to cope with the lack of contact. the potential public health effects of long-term isolation on alcohol use and misuse are unknown (clay & parker, 2020) . it has to be kept in check and under review during the post-confinement period. government officials should provide public health warnings about the risk of excessive consumption in social contexts among young adults and the possibility that older adults maintain their currently increased level of alcohol use. psychological first aid (haider et al., 2020 ; garrido et al., 2019) could be helpful to reduce mental health discomfort caused by the covid-19 crisis. to conclude, we need to consider different age groups when developing strategies for deconfinement as well as the importance of targeting 18-30-year-olds, who have been especially vulnerable. distress due to uncertainty has affected the community, and we need to carefully calibrate communication and deconfinement policies by taking this central dimension into account. authors declare that they have no conflict of interest. table 1 descriptive statistics, chi-square tests and kruskal-wallis one-way analysis of variance between the three subsamples. (1) 18-30 years n=1479 (2) 30-50 years n=885 (3) > 50 years n=507 modalities % (n) % (n) % (n) the validity of the hospital anxiety and depression scale. an updated literature review the psychological impact of quarantine and how to reduce it: rapid review of the evidence the audit alcohol consumption questions (audit-c): an effective brief screening test for problem drinking the psychological impact of the covid-19 epidemic on college students in china increasingly certain about uncertainty: intolerance of uncertainty across anxiety and depression alcohol use and misuse during the covid-19 pandemic: a potential public health crisis? the lancet public health 5, e259 effective health communication-a key factor in fighting the covid-19 pandemic why do people worry? towards a model of uncertainty distress in the context of coronavirus (covid-19) the mental health consequences of covid-19 and physical distancing: the need for prevention and early intervention what works and what doesn't? a systematic review of digital mental health interventions for depression and anxiety in young people student mental health in the midst of the covid-19 pandemic: a call for further research and immediate solutions impact of the covid-19 pandemic on adult mental health tolerance of ambiguity and psychological well-being in medical training: a systematic review mental health outcomes of quarantine and isolation for infection prevention: a systematic umbrella review of the global evidence generalized anxiety disorder, depressive symptoms and sleep quality during covid-19 epidemic in china: a web-based cross-sectional survey the distress of iranian adults during the covid-19 pandemic-more distressed than the chinese and with different predictors online mental health services in china during the covid-19 outbreak social media and emergency preparedness in response to novel coronavirus fear of the coronavirus (covid-19): predictors in an online study a nationwide survey of psychological distress among chinese people in the covid-19 epidemic: implications and policy recommendations we know intolerance of uncertainty is a transdiagnostic factor but we don't know what it looks like in everyday life: a systematic review of intolerance of uncertainty behaviours impact of isolation precautions on quality of life: a meta-analysis mitigating psychological reactance: the role of message-induced empathy in persuasion the psychological impact of sars: a matter of heart and mind in press. recommendations for policy and practice of tele psychotherapy and e-mental health in europe and beyond the effects of communicating uncertainty on public trust in facts and numbers 2020. health, distress and life satisfaction of people in china one month into the covid-19 outbreak the hospital anxiety and depression scale valid percentages have been taken into account, excluding missing data. the sum of the related n can therefore differ slightly from the total n note 2. comparisons = multiple comparisons. this column shows the significant differences between groups (p<.05), using the bonferroni correction key: cord-321497-c7l88gjn authors: tull, matthew t.; edmonds, keith a.; scamaldo, kayla m.; richmond, julia r.; rose, jason p.; gratz, kim l. title: psychological outcomes associated with stay-at-home orders and the perceived impact of covid-19 on daily life date: 2020-05-12 journal: psychiatry res doi: 10.1016/j.psychres.2020.113098 sha: doc_id: 321497 cord_uid: c7l88gjn the covid-19 pandemic has resulted in the widespread implementation of extraordinary physical distancing interventions (e.g., stay-at-home orders) to slow the spread of the virus. although vital, these interventions may be socially and economically disruptive, contributing to adverse psychological outcomes. this study examined relations of both stay-at-home orders and the perceived impact of covid-19 on daily life to psychological outcomes (depression, health anxiety, financial worry, social support, and loneliness) in a nationwide u.s. community adult sample (n = 500; 47% women, mean age = 40). participants completed questionnaires assessing psychological outcomes, stay-at-home order status, and covid-19’s impact on their daily life. being under a stay-at-home order was associated with greater health anxiety, financial worry, and loneliness. moreover, the perceived impact of covid-19 on daily life was positively associated with health anxiety, financial worry, and social support, but negatively associated with loneliness. findings highlight the importance of social connection to mitigate negative psychological consequences of the covid-19 pandemic. the world health organization (who) announced on january 30, 2020 that the severe acute respiratory syndrome coronavirus (covid-19) was a public health emergency of international concern. currently, covid-19 has infected over 4 million people and resulted in over 280,000 deaths worldwide (who, 2020) . currently, approximately 1,350,000 individuals in the u.s. have been infected with covid-19 and over 80,000 have died due to the virus (centers for disease control and prevention [cdc] , 2020). moreover, due to covid-19's long incubation period, ease of transmission, high mortality rate (relative to the seasonal flu), and lack of pharmacological interventions (linton et al., 2020; shereen et al., 2020) , governments have had to implement extraordinary physical distancing interventions to slow the spread of the virus. within the u.s., stay-at-home orders have been implemented in most states and the district of columbia (mervosh et al., 2020) . from a public health perspective, there is strong justification for such interventionsphysically separating people is an effective strategy for preventing the spread of infectious diseases (ahmed et al., 2018; jackson et al., 2014) , including covid-19 (flaxman et al., 2020; thakkar et al., 2020) . however, although stay-at-home orders are vital for protecting physical health (cdc, 2020) , such interventions can also be socially and economically disruptive (chen et al., 2011; reger et al., 2020; thunström et al., 2020) . indeed, recent reviews have suggested that the negative social and economic consequences of current stay-athome orders and the covid-19 pandemic itself (e.g., economic downturn, frequent exposure to distressing media coverage) could contribute to adverse psychological outcomes, including increased loneliness, reduced social support, depression, anxiety, and financial concerns (asmundson & taylor, 2020; courtet et al., 2020; reger et al., 2020) . given the recent and sudden emergence of covid-19, research in this area is understandably limited. however, several studies from china during the initial covid-19 outbreak revealed associations of covid-19 with increased anxiety, depression, and stress (cao et al., 2020; wang et al., 2020; zhang et al., 2020) . further, the overall negative impact of covid-19 on the economy, daily life, social activity, and the ability to work were associated with greater psychological difficulties (cao et al., 2020; zhang et al., 2020) . although research on the psychological outcomes associated with covid-19 is limited, available findings are consistent with those obtained in past studies on the psychological consequences of other pandemics. for example, hawryluck et al. (2004) found that quarantine during the 2003 sars outbreak was associated with high rates of depression (31.2%) and anxiety (28.9%). likewise, elevated levels of anxiety were observed during the 2009 h1n1 pandemic (wheaton et al., 2012) . to extend this research to the psychological impact of covid-19 in the u.s., the present study examined associations of stay-at-home orders and the perceived impact of covid-19 on daily life to relevant psychological outcomes (i.e., depression, health anxiety, financial worry, perceived social support, and loneliness). we predicted that both stay-at-home orders and the perceived impact of covid-19 on daily life would evidence significant positive associations with all psychological difficulties and a significant negative association with social support when controlling for relevant demographic variables. we also predicted a significant interaction of stay-at-home orders and perceived impact of covid-19 on the outcomes of interest, such that the relation of stay-athome order status to negative psychological outcomes would be stronger for participants who perceived covid-19 as having a greater impact on their daily life. participants included a nationwide community sample of 500 adults from 45 states in the u.s. who completed online measures through an internet-based platform (amazon's mechanical turk; mturk) from march 27, 2020, through april 5, 2020. the study was posted to mturk via cloudresearch (cloudresearch.com), an online crowdsourcing platform linked to mturk that provides additional data collection features (e.g., creating selection criteria). mturk is an online labor market that provides "workers" with the opportunity to complete different tasks in exchange for monetary compensation, such as completing questionnaires for research. as such, mturk provided the opportunity to collect a large nationwide sample in a relatively short amount of time, facilitating timely examination of the initial impact of the covid-19 pandemic in the u.s. data provided by mturk-recruited participants have been found to be as reliable as data collected through more traditional methods (buhrmester et al., 2011) . mturk samples also have the advantage of being more diverse than other internet-recruited or college student samples (buhrmester et al., 2011) . for the present study, inclusion criteria included (1) u.s. resident, (2) at least a 95% approval rating as an mturk worker, (3) completion of at least 5,000 previous mturk tasks (referred to as human intelligence tasks [hits]), and (4) valid responses on questionnaires (i.e., assessed by accurate completion of multiple attention check items). participants (47% women; 51.8% men; 0.2% transgender; 0.6% non-binary; 0.4% other) ranged in age from 20 to 74 years (mage = 40.0 ± 11.6). all states in the u.s. were represented, with the exception of delaware, new hampshire, north dakota, vermont, and west virginia. the states with the greatest representation in the sample were florida (11.2%), california (8.6%), pennsylvania (6%), texas (5.6%), new york (5.4%), north carolina (4.6%), michigan (4.4%), ohio (4%), illinois (3.4%), and washington (3%). most participants identified as white (85%), followed by black/african-american (8.4%), asian/asian-american (6.6%), latinx (1.9%), and native american (1.6%). regarding educational attainment, 11.8% had completed high school or received a ged, 35.6% had attended some college or technical school, 43% had graduated from college, and 9.6% had advanced graduate/professional degrees. most participants were employed fulltime (69.2%), followed by employed part-time (16.2%) and unemployed (14.6%). annual household income varied, with 30.6% of participants reporting an income of < $35,000, 33.6% reporting an income of $35,000 to $64,999, and 35.8% reporting an income of ≥ $65,000. regarding household composition, 58.6% of participants reported living alone and the remaining 41.4% reported living with at least one other person (ranging from 2-8 other household members; mean = 3.2 ± 1.1). in addition, 44.1% of participants reported having at least one child in their household (ranging from 1-3 children in the household; mean = 0.72 ± 0.94). few participants reported having sought out testing for covid-19 (1%) or having been infected with covid-19 (0.8%). all procedures received approval from the university's institutional review board. to ensure the study was not being completed by a bot (i.e., an automated computer program used to complete simple tasks), participants first responded to a completely automatic public turing test to tell computers and humans apart (captcha) prior to providing informed consent. on the consent form, participants were also informed that "…we have put in place a number of safeguards to ensure that participants provide valid and accurate data for this study. if we have strong reason to believe your data are invalid, your responses will not be approved or paid and your data will be discarded." data were collected in blocks of nine participants at a time and all data, including attention check items and geolocations, were examined by researchers before compensation was provided. attention check items included three explicit requests embedded within the questionnaires (e.g., "if you are paying attention, choose '2' for this question"), two multiplechoice questions (e.g., "how many words are in this sentence?"), a math problem (e.g., "what is 4 plus 2"), and a free-response item (e.g., "please briefly describe in a few sentences what you did in this study"). participants who failed one or more attention check items were removed from the study (n = 53 of 553 completers). workers who completed the study and whose data were considered valid (based on attention check items and geolocations; n = 500) were compensated $3.00 for their participation. a demographic questionnaire assessed age, sex, annual income, household composition, and racial/ethnic background. covid-19 related experiences and stressors were assessed via a 20-item measure developed for this study. participants were asked about a variety of relevant experiences associated with the covid-19 pandemic. of interest to the present study were two questions from this measure assessing: (1) stay-at-home order status (i.e., "do you live in a state that has instituted a stay-at-home order?" [0 = no; 1 = yes]); and (2) perceived impact of covid-19 (i.e., "to what extent has the situation associated with covid-19 affected the way you live your life?"). participants responded to the latter question using a 5-point likert-type scale ranging from 1 (no impact at all) to 5 (impacted my life a great deal). current depression symptoms were assessed using the depression subscale of the 21-item version of the depression anxiety stress scales (dass-21; lovibond & lovibond, 1995) . participants are presented with a series of statements reflecting the experience of symptoms of depression (e.g., "i found it difficult to work up the initiative to do things," "i felt that i had nothing to look forward to"). participants are instructed to rate each item on a 4-point likert-type scale indicating the extent to which the item applied to them in the past week (0 = "did not apply to me at all", 1 = "applied to me some of the time", 2 = "applied to me a good part of the time", 3 = "applied to me most of the time"). all items from the depression subscale were summed to create one composite score (ranging from 0 -21), with higher scores indicating greater depression symptoms. this measure has demonstrated good reliability and validity (lovibond & lovibond, 1995) . internal consistency of the depression subscale was acceptable (α = .90). the short health anxiety inventory (shai; abramowitz et al., 2007; salkovskis et al., 2002 ) is an 18-item self-report measure assessing health anxiety symptoms. for each item, participants choose one response from a group of four statements of increasing severity (e.g., . the shai has demonstrated good reliability, internal consistency, and construct validity (salkovskis et al., 2002) . all items were summed to create one composite score (ranging from 18 -72), with higher scores indicated greater health anxiety. internal consistency in the present sample was acceptable (α = .93). financial worry was assessed using three items from the family economic strain scale (fess; hilton & devall, 1997) , which assesses concerns about the availability of finances in the future ("i am afraid that my income will decrease;" "i worry about having money to celebrate holidays and other special occasions;" and "i worry about financial matters"). participants rate items on a 5-point likert-type scale ranging from 1 (never) to 5 (always). previous research using the full scale has provided evidence for its reliability and construct validity (hilton & devall, 1997) . all items were summed to create one composite score (ranging from 3 -15), with higher scores indicting greater financial worry. internal consistency of the items used in this study were acceptance (α = 86). the ucla loneliness scale -version 3 (uls-3; russell, 1996 ) is a 20-item self-report measure of perceptions of loneliness and social isolation. participants rate items (e.g., "no one really knows me well;" "i lack companionship;" "there are people i feel close to [reverse scored]") based on how often they apply to themselves on a 4-point likert-type scale ranging from 1 (never) to 4 (often). higher scores are indicative of greater loneliness. the uls-3 has demonstrated adequate test-retest reliability and good construct validity (russell, 1996) . all items were summed to create one composite score (ranging from 20 -80), with higher scores indicating greater loneliness. internal consistency in the present sample was acceptable (α = .94). perceived availability of social support was assessed using the multidimensional scale of perceived social support (mspss; zimet et al., 1988) . the mspss is a 12-item measure designed to assess perceived availability of social support from three primary sources: family (e.g., " i can talk about my problems with my family"), friends (e.g., "i can count on my friends when things go wrong"), and significant others/special persons (e.g., "there is a special person who is around when i am in need"). participants rate items on a 7-point likerttype scale ranging from 1 (very strongly disagree) to 7 (very strongly agree). the mspss has demonstrated good test-retest reliability and discriminant and construct validity (zimet et al., 1988) . all items were summed to create one composite score (ranging from 12 -84), with higher scores indicating greater social support. internal consistency in the present sample was acceptable (α = .96). descriptive statistics for the primary variables of interest (stay-athome order status, perceived impact of covid-19, depression symptom severity, health anxiety, financial worry, loneliness, and social support) were computed, as were point-biserial and pearson product-moment correlations to examine zero-order associations among variables. next, a series of hierarchical linear regression analyses were conducted to evaluate hypotheses. demographic variables (i.e., age, sex, racial/ ethnic background [racial/ethnic minority vs. non-minority], income level [< $50,000/year vs. ≤ $50,000/year], and whether participants lived alone or with others) relevant to the outcome variables were entered in the first step of each model. stay-at-home order status and perceived impact of covid-19 (centered) were entered in the second step of each model, followed by the product of these variables in the third step. depression symptom severity, health anxiety, financial worry, loneliness, and social support served as dependent variables. given that five regression models were conducted, p was set at .01. unstandardized betas are presented to allow evaluation of effect size. a power analysis demonstrated that a sample size of 500 offered sufficient power (≥ .80) to detect a medium effect with an alpha level of p = .01 (faul et al., 2009 ). at the time of data collection, 82.4% (n = 412) of participants were living in states with active stay-at-home orders. participants living in states with stay-at-home orders had been under these orders for an average of 5.71 days (sd = 4.54). descriptive data for and correlations among the primary variables of interest are presented in table 1 . of note, one participant did not complete the perceived impact of covid-19 item and another did not complete the financial worry items. outcomes for all regression models evaluating hypotheses are presented in table 2 . the overall model was significant, accounting for 7% of the variance in depression symptom severity, f (8, 490) = 4.53, p < .001, f = .24. however, neither stay-at-home order status nor perceived impact of covid-19 accounted for a significant amount of unique variance in depression symptom severity above and beyond the covariates, δr 2 = .01, f (2, 491) = 2.16, p = .116, f = .07, although both age and income level were uniquely negatively associated with depression symptom severity in this step of the model. the addition of the interaction between stay-at-home order status and perceived impact of covid-19 did not significantly improve the model, δr 2 = .00, f (1, 490) = .02, p = .879, f = .00. note. p values are presented in parentheses following the correlation statistic. stay-at-home = "do you live in a state that has instituted a stay-at-home order?" (0 = no; 1 = yes); covid-19 impact = "to what extent has the situation associated with covid-19 affected the way you live your life?" the overall model was significant, accounting for 8% of the variance in health anxiety, f (8, 490) = 5.24, p < .001, f = .26. the addition of stay-at-home order status and perceived impact of covid-19 in the second step of the model accounted for significant variance in health anxiety above and beyond covariates, δr 2 = .05, f (2, 491) = 12.02, p < .001, f = .21, with both stay-at-home order status and perceived impact of covid-19 demonstrating significant unique positive associations with health anxiety. likewise, female sex was uniquely positively associated with health anxiety and income level was uniquely negatively associated with health anxiety in this step of the model. the addition of the interaction between stay-at-home order status and perceived impact of covid-19 did not significantly improve the model, δr 2 = .00, f (1, 490) = 1.02, p = .312, f = .01. the overall model was significant, accounting for 14% of the variance in financial worry, f (8, 489) = 9.60, p < .001, f = .37. stay-athome order status and perceived impact of covid-19 accounted for significant unique variance in financial worry above and beyond covariates, δr 2 = .04, f (2, 490) = 10.21, p < .001, f = .19, with both stay-at-home order status and perceived impact of covid-19 emerging as significant unique predictors. in addition, income level was uniquely negatively associated with financial worry in this step of the model. the addition of the interaction between stay-at-home order status and perceived impact of covid-19 did not significantly improve the model, δr 2 = .00, f (1, 489) = 0.27, p = .605, f = .00. the overall model was significant, accounting for 10% of the variance in loneliness, f (8, 490) = 7.08, p < .001, f = .31. the addition of stay-at-home order status and perceived impact of covid-19 in the second step of the model accounted for significant variance in loneliness above and beyond covariates, δr 2 = .04, f (2, 491) = 9.64, p < .001, f = .19. however, whereas stay-at-home order status was significantly positively associated with loneliness, the perceived impact of covid-19 was significantly negatively associated with loneliness. in addition, income level was uniquely negatively associated with loneliness in this step of the model. the addition of the interaction between stay-at-home order status and perceived impact of covid-19 did not significantly improve the model, δr 2 = .00, f (1, 490) = 0.08, p = .783, f = .00. the overall model was significant, accounting for 12% of the variance in perceived social support, f (8, 490) = 8.13, p < .001, f = .34. stay-at-home order status and perceived impact of covid-19 accounted for significant variance in perceived social support above and beyond the covariates, δr 2 = .03, f (2, 491) = 9.27, p < .001, f = .18. however, only perceived impact of covid-19 was uniquely associated with perceived social support, and this association was positive (vs. negative as hypothesized). in addition, income level was uniquely positively associated with perceived social support in this step of the model. the addition of the interaction between stay-at-home order status and perceived impact of covid-19 did not significantly improve the model, δr 2 = .00, f (1, 490) = 0.07, p = .792, f = .00. given evidence of robust age and sex differences in the outcomes of interest (altemus, 2006; borys & perlman, 1985; christensen et al., 1999; luhman & hawkley, 2016) , as well as evidence that the impact of covid-19 may vary as a function of age and sex (dowd et al., 2020; wenham et al., 2020) , a series of hierarchical linear regression analyses were conducted to explore whether age or sex moderated associations between (a) stay-at-home orders and psychological outcomes (2-way interaction); (b) the perceived impact of covid-19 and psychological outcomes (2-way interaction); and (c) the interaction of stay-at-home order status and the perceived impact of covid-19 and psychological outcomes (3-way interaction). none of the examined interactions significantly improved the models. specifically, none of the 2-way or 3way interactions involving age accounted for significant variance in any of the psychological outcomes (δr 2 s = .00 to .01, fs < 1.80, ps > .148, fs < .07). likewise, none of the interactions involving sex accounted for significant unique variance in any psychological outcomes (δr 2 s = .00 to .005, fs < .95, ps > .332, fs = .00). finally, given that the presence of children in the household could exacerbate some of the negative psychological outcomes associated with covid-19 and related stay-at-home orders (e.g., health anxiety, financial worries), an exploratory hierarchical linear regression was conducted to examine the main and interactive effects of having children in the home on psychological outcomes. given the overlap table 2 main and interactive associations of stay-at-home order status and perceived impact of covid-19 to psychological outcomes (n = 500). health anxiety financial worry loneliness social support step note. p values listed as .000 are p < .001. race = racial/ethnic background (0 = racial/ethnic minority, 1 = non-minority); sex (0 = male; 1 = female); income = income level (0 = < $50,000/year; 1 = < $50,000/year); live alone = whether participants live alone or have other individuals in their household (0 = live alone; 1 = live with others); stay-at-home = "do you live in a state that has instituted a stay-at-home order?" (0 = no; 1 = yes); covid-19 impact = "to what extent has the situation associated with covid-19 affected the way you live your life?;" interaction = stay-at-home status × perceived impact of covid-19. between variables representing whether participants lived alone and whether participants had children in their home (χ 2 = 78.91, p < .001), the former variable was removed from this model. results revealed no significant unique associations between having children in the home and any of the psychological outcomes of interest (bs = -.29 to .29, ps > .023). likewise, none of the interactions of having children in the home with stay-at-home order status or the perceived impact of covid-19 were significant in any of the models (δr 2 s = .00 to .008, fs < 1.42, ps > .237, fs < .06). notably, the same pattern of non-significant associations for all main and interactive effects involving having children in the home was found when using a continuous variable reflecting the number of children in the household (vs. the dichotomous variable reflecting the presence or absence of children in the home). the goal of the present study was to examine associations of stay-athome orders and the perceived impact of covid-19 on daily life to relevant psychological outcomes (i.e., depression, health anxiety, financial worry, perceived social support, and loneliness). study hypotheses were partially supported. although the interaction of stay-athome order status and the perceived impact of covid-19 on daily life did not account for significant variance in any of the outcomes, each of these factors was independently associated with several psychological outcomes. as predicted, being under a stay-at-home order was associated with greater health anxiety, financial worry, and loneliness, consistent with the theorized unintended negative consequences of such orders (reger et al., 2020) and past research on the psychological consequences of quarantine during a pandemic (brooks et al., 2020) . moreover, consistent with research on the psychological consequences of covid-19 in china (cao et al., 2020; wang et al., 2020; zhang et al., 2020) and past research on the psychological consequences of other pandemics (tausczik et al., 2012; wheaton et al., 2012) , the perceived impact of covid-19 on daily life was associated with greater health anxiety and financial worry. contrary to predictions, the perceived impact of covid-19 was negatively associated with loneliness and positively associated with social support. stay-at-home orders or experiencing changes to daily life habits due to covid-19 may increase perceptions of risk for harm to one's physical, social, and financial health, resulting in increased health anxiety and financial worry. moreover, stay-at-home orders may result in sudden changes to one's social life. reduced contact with once common social connections may initially bring about increased feelings of loneliness and social isolation. however, findings also suggest that one potential positive outcome of this pandemic may be an increase in social support seeking or connectedness as individuals try to adjust to changes in daily life. although being under a stay-at-home order was associated with increased loneliness, the perception that covid-19 had a greater impact on one's daily life was associated with increased social support and reduced loneliness. these findings are consistent with suggestions that the wide-spread shared experience of covid-19 may increase closeness and social cohesion (courtet et al., 2020) , similar to what has been observed in past mass tragedies (calo-blanco et al., 2017; hawdon & ryan, 2011) . notably, despite evidence that the impact of covid-19 may vary as a function of age and sex (dowd et al., 2020; wenham et al., 2020) , results revealed few associations between age or sex and the psychological outcomes of interest. likewise, none of the examined associations of stay-at-home order status or the perceived impact of covid-19 on daily life with psychological outcomes varied as a function of age or sex. together, these results suggest that the associations of stay-at-home orders and the perceived impact of covid-19 with psychological outcomesat least in the early stages of this pandemic and related public health interventionsdo not differ as a function of age or sex. however, whether these associations will become stronger for individuals of a particular sex or age group as the pandemic persists remains to be determined. conversely, income level was uniquely inversely associated with health anxiety, financial worry, and loneliness, and uniquely positively associated with perceived social support. as such, these findings suggest that individuals with lower incomes may be particularly at-risk for the negative psychological outcomes of covid-19 and related social and economic consequences. as this pandemic and related social distancing interventions persist (even if to a lesser degree), widespread interventions focused on promoting mental health and well-being (including a sense of connection) among less financially secure individuals are also needed. study limitations warrant consideration. the use of cross-sectional data precludes conclusions about the nature or direction of the associations examined. we also do not know the extent with which these psychological symptoms existed prior to covid-19 and the implementation of stay-at-home orders. likewise, self-report questionnaires may be influenced by social desirability or recall difficulties that could affect the validity of provided data. future studies would benefit from incorporating structured clinical interviews and/or timeline follow-back procedures to assess psychological symptoms and their temporal relation to physical distancing or covid-19-related stressors. given our recruitment methods and sample (relatively non-diverse selfselected mturk workers), results may not generalize to the larger u.s. population, other countries, or vulnerable populations (e.g., individuals with chronic medical conditions; health care workers; hospitalized patients). replication of findings is needed within other samples and populations. in addition, results only speak to the early associations of stay-athome orders and the perceived impact of covid-19 to psychological outcomes, and these variables accounted for only a modest amount of the variance in the examined outcomes. longer-term prospective studies are needed to evaluate if the observed relations increase or decrease in magnitude as the pandemic continues. indeed, studies on the trajectory of psychological symptoms over the course of past pandemics have found that, although initial reactions tend to be characterized by elevated levels of anxiety and worry, these symptoms tend to decrease over the course of the pandemic (jones & salathé, 2009; tausczik et al., 2012) . given the relatively high mortality rate associated with covid-19, the lack of adequate testing in some countries, and the absence of effective pharmaceutical interventions for covid-19, it remains to be seen whether a similar trajectory will occur with the current pandemic. finally, it will be important for future research to examine the relation of these psychological outcomes to future adaptive and maladaptive behaviors. for example, individuals with elevated health anxiety may engage in greater help-seeking behavior (e.g., visiting emergency rooms, visiting multiple doctors), taxing health care resources. alternatively, health anxiety may be associated with the avoidance of seeking out care due to fears of contagion, potentially putting the individual's physical health at risk if they are infected with covid-19 or suffering from another medical problem that requires attention (asmundson & taylor, 2020) . likewise, loneliness may contribute to alcohol abuse (åkerlind & hörnquist, 1992) or increased suicide risk (calati et al., 2019; joiner et al., 2012) . despite limitations, results of this study highlight associations between stay-at-home orders, the perceived impact of covid-19 on an individual's life, and a variety of positive and negative psychological outcomes. in the absence of effective infection prevention efforts, widespread testing and tracking, and/or pharmacological interventions (e.g., vaccines) for covid-19, large-scale public health interventions such as physical distancing or stay-at-home orders are necessary to reduce the spread of the virus and infection-related mortality. however, in the context of these necessary public health interventions, results of this study highlight the need for concurrent psychological interventions aimed at mitigating the potential negative psychological consequences of covid-19 and related social distancing interventions, including interventions aimed at increasing social connection and social support (reger et al., 2020) . in particular, as this pandemic persists, it is imperative that 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of working adults in china one month into the covid-19 outbreak the multidimensional scale of perceived social support m. t. tull and k. l. gratz developed the study concept. m. t. tull, k. l. gratz, j. p. rose, k. edmonds, and j. richmond designed the study. k. scamaldo and k. edmonds collected the data. m. t. tull analyzed the data, with assistance from j. richmond and k. scamaldo. m. t. tull, k. edmonds, k. scamaldo, and j. richmond drafted the manuscript, and k. l. gratz and j. p. rose provided critical revisions. all authors approved the final manuscript for submission. authors have no conflicts of interest to declare. supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.psychres.2020.113098. key: cord-337020-7dhx8f4x authors: el haj, mohamad; altintas, emin; chapelet, guillaume; kapogiannis, dimitrios; gallouj, karim title: high depression and anxiety in people with alzheimer's disease living in retirement homes during the covid-19 crisis date: 2020-07-13 journal: psychiatry res doi: 10.1016/j.psychres.2020.113294 sha: doc_id: 337020 cord_uid: 7dhx8f4x to cope with covid-19 and limits its spread among residents, retirement homes have prohibited physical contact between residents and families and friend and, in some cases, even between residents or between residents and caregivers. we investigated the effects of measures against covid-19 on the mental health of participants with alzheimer's disease (ad) who live in retirement homes in france. we instructed on-site caregivers to assess depression and anxiety in participants with mild ad who live in retirement homes. fifty-eight participants consented to participate in the study. the participants rated their depression and anxiety during and before the covid-19 crisis. participants reported higher depression (p = .005) and anxiety (p = .004) during than before the covid-19 crisis. these increases can be attributed to the isolation of the residents and/or to the drastic changes in their daily life and care they receive. while, in their effort to prevent infections, retirement homes are forced to physically separate residents from the outside world and to drastically reduce residents’ activities, these decisions are likely to come at a cost to residents with ad and their mental health. already by mid-spring 2020, covid-19, the disease caused by the novel coronavirus sars-cov-2 that primarily affects the lower respiratory tract, has caused a pandemic affecting the lives and livelihoods of the entire human population around the world. the disease is more severe in older age groups and in the presence of common age-associated comorbidities, such as hypertension, cardiovascular disease and diabetes. consequently, the covid-19 crisis is most drastically affecting the quality of life of older adults, especially those residing in retirement homes in north america and europe, including france. although retirement homes are used to deal with illnesses and deaths, covid-19 has shaken up the functioning of these facilities. to cope with the crisis, retirement homes in france have been restricting, since 15 march 2020, all visitations except for end of life situations. retirement homes have even been forced to restrict all activities considered as non-essential, including restricting access to non-essential personnel (e.g., hairdressers), group activities, and even communal dining. despite the effort of caregivers to provide the best care possible, they have had to struggle with an increased workload (e.g., due to increased vigilance for potential fever and respiratory symptoms, increased requirement to provide postmortem care) and deal with shortages in equipment and supplies, such as sanitizers, gloves and facemasks, potentially exposing them to higher danger for infection. these challenges may have impacted the quality of care, as well as the wellbeing of retirement home residents. regarding the consequences of the covid-19 crisis on mental health of residents of retirement homes, we offer, to the best of our knowledge, the first empirical investigation. we studied the mental health of participants with alzheimer's disease (ad) residing in retirement homes during the covid-19 crisis. more specifically, we investigated their levels of depression and anxiety, since they are among the most prevalent neuropsychiatric symptoms in covid-19 and depression in ad 6 the ad disease spectrum (ismail et al., 2016) and arguably the ones most likely to be affected by the covid-19 crisis. while ad is primarily a neurodegenerative dementia and one of its main cognitive features is memory decline (el haj et al., 2016; mckhann et al., 2011) , the disease is also characterized by the early emergence of various neuropsychiatric symptoms, especially depression and anxiety (ballard et al., 1999; chi, yu, tan, & tan, 2014; ferretti, mccurry, logsdon, gibbons, & teri, 2001; gormley & rizwan, 1998; ismail et al., 2016) . regarding depression, nearly up to 50% of people with ad experience some degree of depression during the course of the disease (starkstein, jorge, mizrahi, & robinson, 2005) , whereas approximately 20% to 30% of people with ad meet criteria for major depressive disorder during the course of the disease (ballard, bannister, solis, oyebode, & wilcock, 1996; enache, winblad, & aarsland, 2011) . risk factors for depression in ad include a personal or family history of depression (lyketsos & olin, 2002; rapp et al., 2006) or apoe4 positivity (krishnan et al., 1996; qiu et al., 2016) . iatrogenic factors may also increase the likelihood of developing depression in ad, such as the use of certain medications, such as benzodiazepines, corticosteroids, and beta-blockers (burke, goldfarb, bollam, & khokher, 2019) . prolonged exposure to dopamine agonists, anticonvulsants, and anticholinergic medications can also increase the likelihood of developing depression in ad (burke et al., 2019) . regardless of its risk factors, depression in ad increases the risk of behavioral disturbance and accelerates functional decline (lyketsos & olin, 2002) . depression in ad also contributes to institutionalization (gaugler, yu, krichbaum, & wyman, 2009 ) and mortality (suh, kil yeon, shah, & lee, 2005) . besides depression, another prominent neuropsychiatric symptom in ad is anxiety. research suggests that 25 % to 71 % people with ad experience anxiety during the course of the covid-19 and depression in ad 7 disease (mintzer, brawman-mintzer, mirski, & barkin, 2005) . anxiety has been also considered as a risk factor for ad, especially anxiety occurring at midlife (gimson, schlosser, huntley, & marchant, 2018) . moreover, anxiety in people with amnestic mild cognitive impairment predicts conversion to ad to a greater degree than memory loss, hippocampal cortex atrophy, or even depression (mah, binns, steffens, & alzheimer's disease neuroimaging, 2015) . the potential pathogenic role of anxiety in ad can be attributed to its negative effects on neuroplasticity and cognitive reserve (i.e., the flexibility or efficiency of cognitive networks) (santabarbara et al., 2019) . anxiety also shares some underlying etiopathogenic mechanisms with ad, such as inflammation and oxidative damage (salim, chugh, & asghar, 2012) . research has also suggested a bi-directional association between anxiety and amyloid-β, a the main pathogenic protein of ad (pietrzak et al., 2015) . regardless of its causes, anxiety in ad has been associated with behavioral disturbance and increased caregiver burden (kaufer et al., 1998) . we hypothesize that symptoms of depression and anxiety are likely to increase in participants with ad who live in retirement facilities during the covid-19 crisis. in their effort to prevent infections, retirement facilities have been forced to physically separate residents from the outside world and to drastically reduce their residents' activities, decisions which are likely to have come at a cost to the residents' mental health. to investigate this issue, we evaluated symptoms of depression and anxiety in participants with ad who live in retirement homes in france during the covid-19 crisis. more specifically, we instructed caregivers to ask participants with ad to rate their depression and anxiety before and during the covid-19 crisis. we expected higher levels of depression and anxiety during than before the covid-19 crisis. covid-19 and depression in ad 8 fifty-eight participants with a clinical diagnosis of probable ad (37 women and 21 men; m age = 71.79 years, sd = 5.54; m years of formal education = 9.26, sd = 2.33) voluntarily participated in the study. they were recruited from retirement homes in france. participants provided their consent to participate. this study was designed and conducted in accordance with the declaration of helsinki. recruitment occurred by contacting colleagues (fourteen psychologists, physicians, or nurses) who work in retirement homes in france, either directly or through social networks (e.g., facebook groups of geriatric caregivers). these on-site caregivers agreed to obtain consent from eligible participants, provide historical information about them and administer study procedures. on-site colleagues were asked to verify, in the medical records, that a diagnosis of probable dementia ad was made by a neurologist or geriatrician according to clinical criteria developed by the national institute on aging and the alzheimer's association criteria for probable alzheimer's disease (mckhann et al., 2011) and that the participants had been assessed with the mini mental state exam (folstein, folstein, & mchugh, 1975) within three months before the study to provide an recent assessment of their cognitive status. due to their increased workload during the crisis, we did not ask on-site caregivers to repeat administration of the mini mental state exam or perform any other clinical test. we selected a score of 21/30 points or higher as an inclusion criterion (raw data is provided in annex, m = 23.03, range 21-26, sd = 1.18) to limit enrollment to participants with mild ad. we did not include participants with a score < 21 points on the mini mental state exam because our study covid-19 and depression in ad 9 required some introspection into psychological states (i.e., participants had to compare their own depression/anxiety before and during the covid-19 crisis). by applying these criteria, we excluded 22 participants from the original sample size (n = 80 participants). twelve participants were excluded because of diagnosis of mixed dementia (e.g., a patient was diagnosed as suffering from both ad and lewy body) and ten participants were excluded because they did not have a mini mental state exam in the last three months. on-site caregivers instructed participants to assess their depression and anxiety with the hospital anxiety and depression scale (zigmond & snaith, 1983) , which consists of 14 items. half of the items evaluates depression (e.g., i feel cheerful, i feel as if i am slowed down, i have lost interest in my appearance) and the other half anxiety (e.g., worrying thoughts go through my mind, i can sit at ease and feel relaxed, i get a sort of frightened feeling like 'butterflies' in the stomach). each item is scored on a four-point scale ranging from 0 (not present) to 3 (considerable). the maximum score for each subscale is 21 points. participants were instructed to rate items on the scale twice. on one occasion, participants were provided with the following instructions: "we would like to evaluate the psychological effects of social distancing implemented to cope with the covid-19 crisis. we thus invite you to fill the following items referring to the period before the beginning of social distancing. for instance, for the following item (i feel cheerful), you should consider it as (i felt cheerful before the beginning of social distancing)". on the second occasion, participants were provided with the following instructions "we would like to evaluate the psychological effects of social distancing implemented to cope with the covid-19 crisis. we thus invite you to fill the covid-19 and depression in ad 10 following items referring to the period of social distancing. for instance, for the following item (i feel cheerful), you should consider it as (i feel cheerful during social distancing)". these instructions were provided orally by on-site caregivers and scores were also provided orally by participants, to minimize the risk of contamination by exchanging paper and pencil materials. to counterbalance the two conditions, half the participants rated the hospital anxiety and depression scale regarding the period before containment, first, and, then, the period during containment, and vice versa. we invited caregivers to note scores on the depression and anxiety subscales and provide us with these scores by phone or email. we compared means on the depression and anxiety subscales between the two conditions (i.e., before vs. during the covid-19 crisis). we used non-parametric tests (i.e., wilcoxon signed rank tests) due to the scale nature of the variables and their abnormal distribution. we also calculated effect size [d = .2 can be considered a small effect size, d = .5 represents a medium effect size and d = .8 refers to a large effect size (cohen, 1988) ] following recommendations by rosenthal and dimatteo (2001) , and ellis (2010) . level of significance was set as p ≤ 0.05. higher depression and anxiety during than before the covid-19 crisis. as illustrated in figure 1 (raw data is provided in annex), participants reported higher depression during (m = 14.21, sd = 3.17) than before (m = 12.34, sd = 4.10) the covid-19 crisis in their effort to limit the spread of covid-19, retirement homes have been reducing physical contact of residents with the outside world, and in some cases, even physical contact between residents. we thus evaluated self-reported indicators of depression and anxiety to assess the mental health of participants with ad who have been living in retirement homes during the covid-19 crisis. analyses demonstrated higher depression and anxiety during than before the covid-19 crisis. our study offers the first assessment of the mental health of people with ad who live in retirement homes during the covid-19 crisis. the higher levels of depression and anxiety during than before the covid-19 crisis, as reported by our participants, may reflect the drastic changes in their daily life in retirement homes during the crisis. retirement homes in france, as well as in our european and north american countries, are currently prohibiting all visitation. nonessential activities and services are also being restricted, including social activities, such as communal dining. in some cases, residents are asked to not leave their rooms and, when in wards, to keep a safe distance from other residents to avoid contracting the virus. in addition, they have not been allowed to have physical contact with their family members and friends, even during sickness. even when not themselves confronted with previously unfathomable situations (i.e., suffering serious physical sickness or being in the end of life without being able to see their families), residents are aware that these situations confront other residents in their facilities. social distancing measures are naturally difficult to bear, especially in the event of death, e.g., when residents of the same unit cannot even say goodbye to the sufferers. while these restrictions may be deemed necessary, they are likely to come at a cost to residents in retirement facilities and their mental health. another factor that may contribute to the depression and anxiety of residents of retirement homes during the covid-19 crisis is the reduced physical contact with caregivers who, despite their efforts to provide the best care, have been dealing with an increased workload, shortages in equipment and supplies, and increased postmortem care. we should note that participants reported high levels of depression and anxiety both before and during the covid-19 crisis. although this may be partly the result of recall bias, these scores reflect the high occurrence of both depression and anxiety in ad (starkstein et al., 2005) . also, 25 % to 71 % people with ad experience anxiety during the course of the disease (mintzer et al., 2005) . both before and during the covid-19 crisis, the depression and anxiety scores of our participants were above the cutoff of > 10/21 points on the hospital anxiety and depression scale recommended by herrmann (1997) . limitations of our study design include the fact that assessments were carried out by onsite caregivers. due to visit restrictions, we had to delegate these assessments to on-site physicians, psychologists and nurses. however, these healthcare professionals are typically trained to assess mental health in people with ad and had already established rapport with participants. to avoid overwhelming on-site caregivers, we did not ask them to perform any additional cognitive or clinical assessments. another limitation of our study is the retrospective assessment of anxiety and depression, with might result in recall bias. that bieng said, the confinement was somehow unpredictable so we were not able to prepare the study and include the pre-assessment. regardless of its potential limitations, largely unavoidable in the current situation, this is the first report on the mental health of people with ad who live in retirement homes during the covid-19 crisis. by demonstrating significant depression and anxiety during the crisis, our study reinforces the calls for clinical interventions to deal with the psychological consequences of this crisis. ideally, psychological therapies (e.g., cognitive and behavioral therapy, mindfulness-based stress reduction meditation) should be offered to residents at the end of the period of social distancing to help them recover. also, future training and education programs for caregivers should benefit from lessons learned during the covid-19 crisis and train caregivers on how to deal with the mental health consequences of similar crises. the prevalence, associations and symptoms of depression amongst dementia sufferers psychiatric morbidity in dementia with lewy bodies: a prospective clinical and neuropathological comparative study with alzheimer's disease diagnosing and treating depression in patients with alzheimer's disease depression in alzheimer's disease: epidemiology, mechanisms, and management statistical power analysis for the behavioral sciences apoe) epsilon4 and episodic memory decline in alzheimer's disease: a review the essential guide to effect sizes: statistical power, meta-analysis, and the interpretation of research results covid-19 and depression in ad 16 depression in dementia: epidemiology, 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years of follow-up the construct of minor and major depression in alzheimer's disease covid-19 and depression in ad 19 mortality in alzheimer's disease: a comparative prospective korean study in the community and nursing homes the hospital anxiety and depression scale the authors would like to thank the caregivers who, despite the increased workload during the covid-crisis, have dedicated their time to answer the survey. the authors would like to thank the patients who have challenged and continue to challenge their isolation during the covid-19 crisis and provided their feedback about their experience during this crisis. the first author was supported by the labex (excellence laboratory, program investment for the future) distalz (development of innovative strategies for a transdisciplinary approach to alzheimer disease) key: cord-349231-9ibv0730 authors: zsido, andras n.; arato, nikolett; lang, andras; labadi, beatrix; stecina, diana; bandi, szabolcs a. title: the connection and background mechanisms of social fears and problematic social networking site use: a structural equation modeling analysis date: 2020-07-24 journal: psychiatry res doi: 10.1016/j.psychres.2020.113323 sha: doc_id: 349231 cord_uid: 9ibv0730 previous research warned that internet and social media use could have a negative effect on the social lives of excessive users. based on the social compensation hypothesis, however, factors related to social fears could lead to problematic social networking site (sns) use because individuals try to compensate for their offline popularity. it was shown that individuals with higher levels of social fears tend to prefer computer-mediated (cmc) instead of face to face (ftf) communication. here, we aimed to create a model that shows the direct and indirect effects of social anxiety and self-esteem on problematic sns use. a total of 215 participants filled out our survey including measures of social anxiety, self-esteem, fear of negative evaluation, social media and internet addiction. using structural equation modeling we tested the indirect and direct effects between the variables. our results indicated that social anxiety and lower self-esteem could lead to favoring cmc over ftf communication, which may result in problematic internet (piu) and sns use as a compensatory behavior to cope with fear of negative evaluation. the indirect pathways might highlight relevant differences behind the motivation of piu – anonymity – and problematic sns use – control. theoretical as well as practical implications are discussed. concern arose that the internet could negatively affect the social lives of excessive users (ahn, 2011). social relationships not only have a crucial role in development but the skills we learn or do not learn affect our later lives as well (dishion and patterson, 2015) . although interaction through the internet, e.g. using social networking sites (sns), can have positive effects such as forming communities and fostering social support (allen et al., 2014; bonetti et al., 2010; yen et al., 2012) , computer-mediated communication (cmc) also comes with a serious pitfall of lacking many social cues (postmes et al., 1998) . the two major features of cmc is anonymity and the control it offers over managing social situations (caplan, 2002; hancock and dunham, 2001) . according to the social compensation hypothesis, i.e. individuals turn to online communication due to their difficulty in forming friendships offline (bonetti et al., 2010; weidman et al., 2012) , these features might be the reason why socially anxious individuals -who feel uncomfortable communicating face-toface (ftf) -prefer cmc instead (pierce, 2009; weidman et al., 2012; yen et al., 2012) . similarly, the compensatory internet use theory (ciut) (kardefelt-winther, 2014) proposes that different forms of problematic internet use (piu) serve as a compensatory behavior to cope with existing problems (wolniewicz et al., 2018) such as shyness (chak and leung, 2004) , loneliness (caplan, 2007) , and fear of missing out (wolniewicz et al., 2018) . thus, in the present study, we investigated whether individuals with higher levels of social anxiety are more likely to prefer cmc over ftf communication due to either the anonymity or the control offered by the internet, and snss in particular, over social interactions. according to the ciut, we used increased piu and problematic sns use as indicators of favoring cmc over ftf communication. our results may help to find effective preventive methods of problematic sns use and to aid individuals with higher levels of social anxiety. 5 a defining characteristic of social anxiety is fear of social or performance situations in which the person is exposed to possible scrutiny by others (american psychiatric association, 2013; bögels et al., 2010; stein and stein, 2008) . that is, people with social anxiety fear that this scrutiny could be embarrassing or humiliating and that others will judge them in a negative way. indeed, it was shown (winton et al., 1995) that people with higher levels of social anxiety have a bias towards identifying others' emotional expressions as negative. fear of negative evaluation in social situations (winton et al., 1995) and distorted negative selfbeliefs (goldin et al., 2009 ) could indicate a vulnerability to social anxiety; possibly because such individuals show a reduced tendency to self-favoring compared to others (de jong, 2002) . further, low self-esteem could increase the possibility of developing problematic sns use (baturay and toker, 2017) . indeed, the anticipation of negative evaluation by others in individuals who have lower self-esteem can result in anxiety in social situations (kocovski and endler, 2000) . low self-esteem (you et al., 2019) plays an important role in the development of social anxiety. the anonymity and control of the internet and cmc could set such individuals free from references to prior negative experiences related to social situations (young and lo, 2012) . thus, individuals with low self-esteem could also favor cmc over ftf communication. previous studies (pierce, 2009; prizant-passal et al., 2016; yen et al., 2012) showed that social anxiety was lower in highly socially anxious individuals when using cmc, resulting in feelings of relative comfort at online platforms. social anxiety is a shared precursor of the development of piu (yen et al., 2012) . it was also shown that low self-esteem was positively related to piu (kahraman and demirci, 2018; kim and davis, 2009) . while it has been proposed that psychological benefits could be derived from cmc (allen et al., 2014; bonetti et al., 2010; yen et al., 2012) , long-term effects of problematic sns use could include cyberbullying behavior and depression (kircaburun et 6 al., 2018) , higher alienation from peers (assunção and matos, 2017), victimization (martínez-ferrer et al., 2018) and loneliness (moody, 2001) . therefore, it is vital to map possible points of intervention to help socially anxious people avoid piu and problematic sns use. nonetheless, results are still mixed which could be due to the fact that the majority of the aforementioned studies are still only correlational in nature. there is a strong call (prizant-passal et al., 2016) to establish causal relationships between social anxiety and internet use. in the present study we sought to test a possible model on the connection and background mechanisms of social anxiety and problematic sns use (see figure 1 ). in this model, we hypothesized that social anxiety and self-esteem (level 1) will facilitate fear of negative evaluation in face-to-face social situations (level 2). in turn, negative evaluation would lead to heightened piu and problematic sns use (i.e. seeking online anonymity and control by favoring cmc communication, level 3). we recruited 215 caucasian participants (132 females), aged 18-60 years (m=33.81, sd=14.59) through the internet by posting invitations on various forums and mailing lists to obtain a heterogeneous sample. the data were collected in 2019, before the covid-19 pandemic. the participants filled out the questionnaires online, using google forms, on a voluntary basis. none of them reported having a psychiatric disorder. additionally, we deleted three invalid entries (one duplication and two fakes), thus they were not analyzed. the research was approved by the hungarian united ethical review committee for research in psychology and was carried out in accordance with the code of ethics of the world medical association (declaration of helsinki). informed consent was obtained from all participants. the rses contained 10 items (urbán et al., 2014 ) rated on a 4-point likert-type scale. higher scores indicate more positive self-esteem. the cronbach's alpha was .89. we used the 8-item brief version of the fne questionnaire (perczel-forintos and kresznerits, 2017; weeks et al., 2005) . all items are rated on a 5-point likert-type scale with higher scores implying higher fear of negative evaluation by others. the cronbach's alpha was .93. we used the 6-item version of the sps (peters et al., 2012) the questionnaire consists of 18 items and three subscales: obsession, neglect, and control disorder. all items are answered on a 5-point likert-type scale. the three subscales add up to the total score, where a higher score signifies a higher level of problematic internet use (demetrovics et al., 2008) . the cronbach's alpha was .88. problematic sns use was measured with the bergen social media addiction scale (bsmas). the bsmas contains six items reflecting core addiction elements regarding sns use (andreassen et al., 2016; bányai et al., 2017) . items are rated on a 5-point likert-type scale. higher scores imply higher levels of problematic social media use. the cronbach's alpha was .87. we performed a structural equation modelling using the jasp statistical software version 0.11.1 for windows (jasp team, 2019) utilizing the lavaan (v. 0.6-1) package for r (rosseel, 2012) to assess fit measures for our proposed models. we used the diagonally weighted least squares (dwls) estimator (bandalos, 2014) . to evaluate model fit, we used the chisquare, the comparative fit index (cfi), the tucker-lewis index (tli), and the root mean square error of approximation (rmsea) the cutoffs for good model fit were nonsignificant chi-square (kline, 1998) , cfi and tli values of .95 or greater (hu and bentler, 1998) , rmsea value of .08 or lower (browne and cudeck, 1992) . for the indirect pathways, we also calculated the percentage of indirect effects. .052, 90%ci = [.00 -.14], srmr = .032). in line with our hypothesis sps (β = .55, p < .001) and rses (β = -.38, p < .001) scores predicted bfne (r 2 = .66). further, bfne predicted both piuq scores (β = .49, p < .001, r 2 = 0.24) and bsmas (β = .44, p < .001, r 2 = 0.19). we did not find a direct effect from rses or sps to either piuq (β = .07, p = .296 and β = .02, p = .787, respectively) or bsmas (β = -.01, p = .891 and β = .11, p = .081, respectively). regarding the indirect pathways, we found that sps through bfne predicted both piuq (β = .27, p < .001, 93.4%) and bsmas (β = .24, p < .001, 65.9%) scores. similarly, rses predicted both piuq (β = -.19, p < .001, 74.5%) and bsmas (β = -.17, p < .001, 95.5%) scores through bfne. regarding covariances, sps and rses (β = -.50, p < .001), and piuq and bsmas (β = .65, p < .001) scores showed strong covariances as expected. see figure 1 for the model and table 1 the goal of our study was to test a model on the connection and background mechanisms of social anxiety and problematic sns use. we proposed that that higher levels of social anxiety and lower self-esteem will facilitate fear of negative evaluation. through fear of negative evaluation, these would lead to problematic internet use and problematic sns use, probably due to favoring cmc over ftf communication. our results are in line with that of previous studies (pierce, 2009; stein et al., 2001; stein and stein, 2008; weidman et al., 2012; yen et al., 2012) showing that highly socially anxious individuals prefer using cmc over ftf because it reduced their anxiety. the novelty of the present study is that we showed that heightened social anxiety as well as low self-esteem could result in the overuse of the internet and snss and that this happens due to fear of negative evaluation of others. our findings may lend further support to the social compensation hypothesis (bonetti et al., 2010; weidman et al., 2012) and the ciut (kardefelt-winther, 2014) such that social anxiety and lower self-esteem could lead to favoring cmc -indicated by higher scores on problematic internet and sns use measures -as a compensatory behavior to cope with fear of negative evaluation. the overview of the hierarchical organization of the model provides several important implications. social anxiety had a significant role in piu and problematic sns use through the mediating effect of fear of negative evaluation. according to our results, fear of negative evaluation seems to be the maladaptive social evaluating mechanism that socially anxious individuals compensate for through piu and problematic sns use. features such as the anonymity, feeling of control and cmc might be more appealing for individuals who suffer in ftf situations because of their fears of others' negative opinions. the role of the appearance of evaluation-based factors could be helpful for possible interventions such as cognitivebehavior therapy approaches focusing on averting the accretion of distorted cognitions potentially leading to social phobia (dogaheh et al., 2011; shirotsuki and noda, 2019) . in fact, higher levels of self-esteem could also have a protective role based on its effects on the fear of negative evaluation in our model. this is consonant with previous empirical results (cheng et al., 2015; perczel-forintos and kresznerits, 2017) and also in line with previous research highlighting the role of self-esteem and fear of negative evaluation in social anxiety (kocovski and endler, 2000; you et al., 2019) . our model supports the social compensation hypothesis (bonetti et al., 2010; weidman et al., 2012) such that individuals who fear negative evaluation by others or having higher levels of social anxiety will favor cmc over ftf due to the reduction in social cues and the control afforded by the internet because they will feel more comfortable while communicating with others (allen et al., 2014; valkenburg and peter, 2009 ). the indirect pathways might also highlight relevant differences behind the motivation of piu and problematic sns use. that is, social anxiety through fear of negative evaluation leads to higher levels of sns use which, as an epiphenomenon, also means higher scores on piu. the key here could be that socially anxious individuals will rely on the control over social interactions offered by social media sites. in contrast, negative self-esteem and fear of negative evaluation could also lead to the heightened use of snss, but presumably, the ones that offer anonymity to the user (e.g. forums), i.e. "hiding" behind cmc but meanwhile maintaining the seeking for social interactions. the described mechanisms contribute to the preference of cmc above ftf, which was found to be a possible vulnerable aspect of social functioning (postmes et al., 1998; ruppel et al., 2017; van der meijden and veenman, 2005) . although the high correlation between piu and problematic sns use might also be a limitation, the shared variance (approx. 50%) showed that while these problematic behaviors share a common root, they also have unique features (bányai et al, 2017) , which might be a proof for the different motivation we discussed. to sum up, our findings imply that personality-based constructs such as self-esteem and social anxiety could affect behavioral processes, e.g., piu and problematic sns use, yet the role of the mediating components is also important. our model provides an opportunity to better understand the complex interaction of clinically relevant constructs and identify potential aspects for intervention. the dispute over the relevance of ftf and cmc forms of social interactions is proved to be an ideal explanatory-framework for a better understanding of these processes. further longitudinal research is needed to clearly and directly understand their exact role in the appearance and prevalence of internet-and social-media related behavioral addiction. limitations of our study include a theoretical assumption of our model placing selfesteem and social anxiety at the same level and therefore allowing a covariance between them. this technical construction does not allow us to identify a causal relationship in the case of the two root-variable, further investigations are needed to clarify the nature of the association. another important aspect could be, in future studies, the question of probable gender differences. in the case of social anxiety, the female dominance is fairly described (asher et al., 2017) , similarly, previous review articles indicate that females can be described with a relatively lower level of self-esteem compared to males (bleidorn et al., 2016) . the role of these imbalances and their possible effects on the further levels of our model is still unclear. although the main goal of the present study was to show whether social anxiety, self-esteem, and fear of negative evaluation can have a role in the development of problematic internet and sns use, the amount of explained variance by the model indicated that there might be other key factors at play. future research should aim to explore other major factors that could facilitate problematic sns use and, thus, help preventive work. these limitations notwithstanding, we showed that personality-based self-reflective psychological constructs could effectively influence the behavioral level of our everyday functioning. in this process, the most important aspect is the role of the mediating variables. identifying them and clearly define their role could provide potential and promising opportunities for working out preventive psychological options to avoid the emergence of maladaptive behaviors. our results may also have implications on the current shift from offline to online communication due to the covid-19 pandemic. although this shift might result in heightened piu and problematic sns use, but perceived social support could be a relative performance of categorical diagonally weighted least squares and robust maximum likelihood estimation problematic social media use: results from a large-scale nationally representative adolescent sample self-esteem shapes the impact of gpa and general health on facebook addiction age and gender differences in self-esteem -a cross-cultural window social anxiety disorder: questions and answers for the dsm-v 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adolescents engaged in the problematic use of social networking sites more involved in peer aggression and victimization? internet use and its relationship to loneliness szociális szorongás és önértékelés: a "félelem a negatív megítéléstől" (félne) kérdőív hazai adaptációja development of a short form social interaction anxiety (sias) and social phobia scale (sps) using nonparametric item response theory: the sias-6 and the sps-6 social anxiety and technology: face-to-face communication versus technological communication among teens breaching or building social boundaries? side-effects of computer-mediated communication social anxiety and internet use -a metaanalysis: what do we know? what are we missing? lavaan: an r package for structural equation modeling reflecting on connecting: meta-analysis of differences between computer-mediated and face-to-face self-disclosure cognitive behavior therapy and mindfulness-based intervention for social anxiety disorder, in: anxiety disorders 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negative affect, fear of missing out, and fear of negative and positive evaluation social anxiety in online and real-life interaction and their associated factors how does self-esteem affect mobile phone addiction? the mediating role of social anxiety and interpersonal sensitivity cognitive appraisal mediating relationship between social anxiety and internet communication in adolescents cognitive-social sources of wellbeing: differentiating the roles of coping style, social support and emotional intelligence key: cord-273331-pu4cr3bh authors: pinkham, amy e.; ackerman, robert a.; depp, colin a.; harvey, philip d.; moore, raeanne c. title: a longitudinal investigation of the effects of the covid-19 pandemic on the mental health of individuals with pre-existing severe mental illnesses date: 2020-10-01 journal: psychiatry res doi: 10.1016/j.psychres.2020.113493 sha: doc_id: 273331 cord_uid: pu4cr3bh objective: individuals with severe mental illnesses (smi), including schizophrenia spectrum illnesses and affective disorders, may be at increased risk for negative mental health outcomes related to the covid-19 pandemic. this study compared the severity of pre-pandemic symptoms and affective experiences to current symptoms to evaluate this possibility. methods: 148 individuals with smi (92 with schizophrenia spectrum illnesses and 56 with affective disorders) were recruited from ongoing ecological momentary assessment studies that sampled day-to-day experiences and symptom severity prior to the pandemic. participants completed a one-time phone survey that queried these same experiences/symptoms between april and june of 2020. results: severity of affective experiences and psychotic symptoms remained stable across time, as did sleep duration. well-being and the number of substances used increased during the early months of the pandemic. increases in well-being were associated with being female and spending less time alone pre-pandemic. patterns of stability/change did not differ according to diagnostic category. conclusions: at this relatively early stage, individuals with smi are not reporting a worsening of symptoms or affective experiences and instead appear to be resilient in the face of the pandemic. continued assessment is needed to determine whether this resilience will persist as the pandemic progresses. the covid-19 pandemic has caused significant societal disruptions and dramatically impacted day-to-day behaviors and experiences. a burgeoning literature also demonstrates a strong link between the pandemic and mental health symptoms such as anxiety and depression (rajkumar, 2020) that has prompted some to predict a subsequent second pandemic of mental health conditions (choi et al., 2020) . supporting these assertions, a survey conducted in china among the general population in late january/early february 2020 reported moderate to severe anxiety symptoms in 28.8% of their sample and moderate to severe depressive symptoms in 16.5% of participants (wang et al., 2020) . slightly higher incidences were reported in a larger study also conducted in china in february 2020, with 35.1%, 20.1%, and 18.2% of survey respondents endorsing significant anxiety, depression, and sleep impairment, respectively (huang and zhao, 2020 ). an even later survey, which took place from the end of march 2020 to the end of may 2020 reported that 65.6% of the sample reported clinical levels of depression, anxiety, or stress (tso and park, 2020) , perhaps suggesting that the mental health impact may increase with longer duration of the pandemic. similar negative outcomes have also been reported in an american survey of the general population, where mean depression scores were above clinical cutoff, and over 25% of participants reported moderate to severe anxiety (fitzpatrick et al., 2020) . while it is unclear whether exceeding cutoffs on screening measures like those used in these cross-sectional survey studies (e.g., the depression anxiety stress scales) will equate to meeting clinical criteria, these findings indicate widespread negative impacts on mental health among members of the general population. many experts have suggested that the covid-19 pandemic may have an even more detrimental effect on individuals with pre-existing mental health conditions (pfefferbaum and north, 2020) , and in particular, those individuals with severe mental illnesses (smis) such as 5 schizophrenia (kozloff et al., 2020) and bipolar disorder (stefana et al., 2020) . for example, individuals with smi may experience symptom exacerbations due to increased stress and greater risk of relapse due to disruptions in treatment delivery and availability (chatterjee et al., 2020) . prevention strategies such as social distancing may also inadvertently worsen the symptoms of individuals with smi, as these individuals may be more susceptible to isolation and loneliness (hamada and fan, 2020) . indeed, the few available empirical studies examining current symptoms have reported greater depression, anxiety, and stress in individuals with self-reported affective disorders (i.e., bipolar disorder or major depressive disorder) as compared to individuals without an affective disorder (van rheenen et al., 2020) and among individuals with smi (i.e., bipolar disorder or psychotic disorder) relative to psychiatrically healthy controls (gonzález-blanco et al., 2020) . another cross-sectional study conducted in india found that 30% of individuals with smi reported a re-emergence of psychiatric symptoms during covid-19 lockdown (muruganandam et al., 2020) . finally, there is also some suggestion of a differential impact across diagnoses such that individuals with affective disorders report greater covid-19related stress relative to individuals with schizophrenia spectrum illnesses (hölzle et al., 2020) . while the studies reviewed above provide some evidence for a disproportionately negative impact on individuals with smi, longitudinal studies with pre-pandemic data are necessary to accurately gauge the impact of the covid-19 pandemic on individuals with preexisting mental health conditions. to our knowledge, no studies have been conducted thus far that compare symptoms or affective experiences before and after the onset of the pandemic in individuals with smi. however, one such study in college students found no increase in psychotic experiences during the pandemic (hajdúk et al., 2020) , and a study of older adults with pre-existing major depressive disorder counterintuitively found lower depression and anxiety 6 during the pandemic (hamm et al., 2020) . thus, it is possible that individuals with smi may actually be somewhat resilient to the effects of the covid-19 pandemic, but this remains untested. our research team has two ongoing nimh-funded studies specifically focused on smi that have cumulatively enrolled 232 individuals with diagnoses of schizophrenia, schizoaffective disorder, bipolar disorder (with or without psychotic features), or major depressive disorder with psychotic features (moore et al., 2020) . in both studies, participants completed self-ratings of symptom severity and daily mood experiences via ecological momentary assessments (ema) administered multiple times each day over several days. here, we contacted participants who had previously completed these parent studies via phone and asked them to answer the same questions that were included in the ema questionnaires. survey responses were collected between april 3, 2020 and june 4, 2020. the key aim of this report is therefore to compare prepandemic and current symptom ratings to identify the impact of the pandemic on mental health among individuals with pre-existing smi. we also examined how factors such as broad diagnostic category (i.e., schizophrenia spectrum vs. affective disorders), typical daily activities (e.g., time spent alone), and demographic factors relate to change over time. of the 232 individuals enrolled in our ongoing studies, 148 participated in the phone survey. participants diagnosed with either schizophrenia or schizoaffective disorder were included in the schizophrenia spectrum group (n=92), and participants diagnosed with bipolar disorder (i or ii) with or without psychotic features or major depression with psychotic features were included in the affective disorders group (n=56). diagnoses were determined at baseline 7 study visits using the mini international neuropsychiatric interview (mini) (sheehan et al., 1998) and the psychosis module of the structured clinical interview for dsm-5 (scid-5) (first et al., 2015) . raters were trained on administration and scoring through videotape and practice interviews to acceptable inter-rater reliability (icc > 0.80). demographic characteristics of the study sample are presented in table 1 . all participants were recruited from the university of california san diego (ucsd), the university of miami (um), and the university of texas at dallas (utd) through online advertisements and/or flyers at outpatient clinics. inclusion and exclusion criteria varied slightly across studies, but in general, participants were adults aged between 18 and 65 with estimated iq>70, as indicated by word reading performance on either the wide range achievement test-3 (wrat-3) (wilkinson, 1993) or the wrat-4 (wilkinson and robertson, 2006) . no participants were receiving inpatient care, and all participants were free from neurological and/or neurodegenerative disorders. the institutional review boards at all three study sites approved the survey protocol, and all participants provided verbal consent for this survey. 2.2.1. baseline clinical characteristics. as part of the parent studies, participants first completed a baseline visit during which diagnosis and study eligibility were confirmed and clinician ratings of symptom severity were obtained. the positive and negative syndrome scale (panss) (kay et al., 1987) was used to assess the severity of positive, negative, and general symptoms. severity of depression symptoms was assessed using the montgomery-asberg depression rating scale (madrs) (montgomery and åsberg, 1979) , and severity of manic symptoms was assessed using the young mania rating scale (ymrs) (young et al., 1978) . the 8 scale to assess unawareness of mental disorder (sumd) was used to evaluate insight into illness (amador et al., 1993) . descriptive statistics are provided in table 1 . participants were then given a study-provided samsung galaxy s8 smartphone that was used to administer the ema portion of the parent study. ema questionnaires were developed by authors cad, pdh, rcm, and aep and were administered three times per day for either 30 days (study 1) or 10 days (study 2). data collection for study 1 began on dec. 4, 2018 and for study 2 on july 11, 2019, and enrollment is currently ongoing for both. overall response rates to ema questionnaires for individuals in the current sample was high, with participants completing 77.9% (sd=22.2%) of all assessments in study 1 (n=80) and 84.3% (sd=16.8%) of all assessments in study 2 (n=68). questionnaires for both studies included items about engagement in daily activities and social interactions (i.e., -where are you?‖, -who are you with?‖, -what are you doing?‖) for which participants selected responses from a drop-down list. mood and psychotic symptoms (e.g., -since the past alarm, how much have you felt sad or depressed; since the last alarm how much have heard voices‖) were also queried and rated on a scale from 1 (not at all) to 7 (very much). specific mood experiences included feeling sad/depressed, energized/excited, and happy; and specific psychotic symptoms were hearing voices and having paranoid thoughts. one additional question regarding sleep quantity (reported in hours/minutes) was asked at only the first survey of the day, and two additional questions were asked only at the last survey of the day -substances used (selected from a drop-down list) and overall level of well-being (rated from 1-7). to assess current symptoms, the same five mood and psychotic symptom questions from the ema questionnaires were administered via phone. the questions 9 regarding sleep, substance use, and well-being were also asked, and the response format was identical to that used for the ema questionnaires. 2.3.1. ema data processing. to obtain estimates of pre-pandemic activity, responses to the three activity questions were first dichotomized to home vs. away; alone vs. with others, and working vs. other activity. the percentage of surveys with each category of response was then calculated and used in subsequent analyses. ratings of moods, symptoms and reports of wellbeing were also averaged across all completed surveys for each participant to quantify prepandemic symptom severity. sleep quantity was also averaged across all completed surveys, and for substance use, the number of substances used at each query were summed and then averaged across the total number of completed surveys. on average, ema periods for study 1 covered 28.8 days (sd=4.62 days), and ema periods for study 2 covered 9.97 days (sd=5.12 days). to assess representativeness of the current sample, demographic, baseline clinical characteristics, and ema responses were first compared between those individuals in the parent studies who completed the survey (i.e., participants) and those who did not (i.e., non-participants). the effect of the pandemic on affective experiences, symptoms, and behavioral health (i.e., sleep and substance use) was then assessed via a series of repeated measures anovas that used time as the within-subject variable (pre-pandemic ema averages vs. current survey responses) and diagnostic category as the between-subjects variable (schizophrenia spectrum vs. affective disorders). in these analyses, elapsed time between the beginning of the ema period and the current survey (mean (sd)=225.55 (115.82) days) was included as a covariate, and the p-value for significance was set at .05. pearson's r correlations between pre-and during-pandemic ratings were also calculated for the sample as a whole and for each diagnostic category to assess within-group rank order stability of scores over time. to examine factors that may be related to change over time, we then calculated change scores for each of the dependent variables (during-pandemic rating minus pre-pandemic rating) and computed partial correlations with these change scores and demographic factors and ema activity while controlling for elapsed time. categorical independent variables were assessed with one-way ancova. additionally, the potential contribution of variability during the ema period to changes pre-vs. during-pandemic was also examined by first calculating the intraindividual standard deviation for ratings of each outcome variable (i.e., moods, symptoms, sleep, substances used, and well-being) across all completed surveys for each participant. the correlation between these values and change scores was then computed while again controlling for elapsed time. given the large number of comparisons examined in these last analyses of potentially contributing factors, only results significant at p<.01 are reported. the participant group had a significantly higher percentage of females (60.8%) relative to the non-participant group (42.9%) (χ 2 (1)=6.96, p=.008) and had completed more years of education (participant mean=13.36, sd=2.63 vs. non-participant mean=12.51, sd=2.49; t(230)=2.44, p=.016). there were no significant differences between participants and nonparticipants on any of the other demographic factors, including diagnosis, (all ps>.14) or baseline clinical characteristics/symptoms (all ps>.07). groups also did not differ on mean levels of activity (i.e., being alone, being home, or working) during the ema period or on ema responses of affective experiences or symptom severity, sleep duration, or well-being. participants reported 11 using a greater number of substances (mean=0.65, sd=0.69) than non-participants during the ema period (mean=0.47, sd=0.60; t(215)=2.04, p=.043). descriptive statistics for all pre-and during-pandemic ratings are provided in table 2 . the series of repeated measures anovas revealed a number of significant main effects of group indicating higher ratings of feeling energized (f(1,145) correlations between pre-and during-pandemic ratings were of medium to large effect sizes (see table 3 ) indicating good rank order stability over time. this was most evident in the sample as a whole; however, within the separate diagnostic categories, there were a few symptoms that were less stable (e.g. paranoia for the schizophrenia spectrum group and hearing voices for the affective disorders group). a comparison of strength of correlations between groups using the fisher r-to-z transformation revealed significantly stronger associations between pre-and during-pandemic scores in the schizophrenia spectrum group for hearing voices (p=.03) and well-being (p=.011) and stronger associations in the affective disorders group for paranoia (p=.009). to assess factors that may contribute to greater pandemic-induced change, all demographic and clinical factors listed in table 1 potential effects of site (utd vs. ucsd vs. um) and parent study (study 1 vs. study 2) on change over time were tested using a series of one-way anovas and two-sample t-tests, respectively. amount of change did not differ across sites for any of the affective experiences, symptoms, or behavioral health outcomes (all ps≥.10). similarly, change across time did not differ depending on parent study for any of the variables of interest except for substance use (study 1 mean=.40, sd=.86 vs. study 2 mean=-.14, sd=.67; t(145)=4. 19, p<.001) . the repeated measures anova on number of substances used was therefore repeated while controlling for parent study. the main effect of time remained significant f(1,144)=21.97, p<.001, η p 2 =.132), and the main effect of group and interaction remained non-significant (both p>.40). this study examined the effects of the covid-19 pandemic on the day-to-day mental health of individuals with pre-existing severe mental illness by comparing pre-pandemic ratings of symptom severity and behavioral health to ratings collected during-pandemic. contrary to expectations, there were no significant changes in mood experiences or psychotic symptoms over time, and sleep duration was also unaffected. participants did report a small but significant increase in the number of substances used, and somewhat surprisingly, participants also reported 14 a significant increase in well-being post-pandemic onset. diagnostic category (i.e. schizophrenia spectrum illness vs. affective disorder) did not have any impact on these results, suggesting that they apply broadly to smi. thus, the lack of symptom exacerbations and increase in well-being suggest that individuals with smi, regardless of specific diagnosis, coped relatively well in the early months of the pandemic and did not experience negative effects on their day-to-day mental health. it is difficult to determine what may be contributing to the increase in number of substances used and well-being. our examination of contributing factors did not identify any systematic associations for substance use and indicated that for well-being, only being female and spending less time alone were related to increased ratings. it is not clear why women with smi would report a greater increase in well-being than males, particularly given conflicting evidence from the general population (pieh et al., 2020) ; however, this suggests an important distinction related to gender in smi that deserves further study. the finding that spending less time alone pre-pandemic was associated with increased well-being during-pandemic is consistent with studies showing that social support is associated with resiliency (liu et al., 2020) . here, being alone less frequently pre-pandemic may be indicative of larger or higher quality social networks that are able to be drawn upon during-pandemic and that may increase one's sense of overall well-being. when considering these findings, aspects of the study design should be noted. strengths include the sample size, inclusion of both schizophrenia spectrum illnesses and affective disorders, and availability of ema data. by averaging multiple days of assessments, estimates of pre-pandemic experiences and symptoms are likely to be highly precise, thus maximizing the ability to detect change due to the pandemic. limitations include the possibility of selection bias, 15 which should be considered when generalizing these results to other individuals with smi. while there were few differences between survey participants and non-participants, participants were more likely to be female, to have more years of education, and to use a greater number of substances relative to non-participants. second, our results regarding substance use pertain only to the number of substances being used and not amounts of use or whether or not that use is problematic. finally, it is important to emphasize that data were collected relatively early in the pandemic and only at one timepoint between the beginning of april and may of 2020. texas, california, and florida all enacted school closures beginning in mid-march, and the governing bodies of all three sites had also either mandated or recommended the closure of non-essential retail and commercial establishments (e.g., restaurants, bars, gyms, etc.) prior to the beginning of our survey period. the number of positive cases climbed steadily from 274,143 on april 3, 2020 to 1,862,656 on june 4, 2020, as did the number of deathsfrom 6,496 to 108,064 (centers for disease control and prevention, 2020). thus, our survey period captures a time of exponential growth in covid-19 cases/deaths and unprecedented governmental attempts to slow spread of the virus that represents a critical period of the pandemic. however, it is quite possible that negative effects make take time to accrue (e.g., as the economy continues to be impacted, as -quarantine fatigue‖ assessment of insight in psychosis impact of covid-19 pandemic on pre-existing mental health problems a second pandemic: mental health spillover from the novel coronavirus (covid-19) structured clinical interview for dsm-5-research version (scid-5 for dsm-5 fear of covid-19 and the mental health consequences in america covid-19 lockdown in people with severe mental disorders in spain: do they have a specific psychological reaction compared with other mental disorders and healthy controls psychotic experiences in student population during the covid-19 pandemic the impact of covid-19 on individuals living with serious mental illness experiences of american older adults with pre-existing depression during the beginnings of the covid-19 pandemic: a multi-city, mixed-methods study covid-19 distresses the depressed while schizophrenic patients are unimpressed: a study on psychiatric inpatients chinese mental health burden during the covid-19 pandemic. asian journal of psychiatry 51 the positive and negative syndrome scale (panss) for schizophrenia the covid-19 global pandemic: implications for people with schizophrenia and related disorders calculating and reporting effect sizes to facilitate cumulative science: a practical primer for t-tests and anovas factors associated with depression, anxiety, and ptsd symptomatology during the covid-19 pandemic: clinical implications for us young adult mental health a new depression scale designed to be sensitive to change assessing the real-time mental health challenges of covid-19 in individuals with serious mental illnesses: protocol for a quantitative study covid-19 and severe mental illness: impact on patients and its relation with their awareness about covid-19 mental health and the covid-19 pandemic the effect of age, gender, income, work, and physical activity on mental health during coronavirus disease (covid-19) lockdown in austria covid-19 and mental health: a review of the existing literature. asian journal of psychiatry the mini-international neuropsychiatric interview (m.i.n.i.): the development and validation of a structured diagnostic psychiatric interview for dsm-iv and icd-10 the covid-19 pandemic is a crisis and opportunity for bipolar disorder alarming levels of psychiatric symptoms and the role of loneliness during the covid-19 epidemic: a case study of hong kong mental health status of individuals with a mood-disorder during the covid-19 pandemic in australia: initial results from the collate project: covid-19 and mood disorders immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china wrat-3: wide range achievement test administration manual. wide range wide range achievement test 4 professional manual a rating scale for mania: reliability, validity and sensitivity quarantine fatigue: first-ever decrease in social distancing measures after the covid-19 pandemic outbreak before reopening united states we would like to thank all of the individuals who participated in this study and the following individuals for their assistance with data collection and management: cassi key: cord-320509-3a40djjm authors: benke, christoph; autenrieth, lara k.; asselmann, eva; pané-farré, christiane a. title: lockdown, quarantine measures, and social distancing: associations with depression, anxiety and distress at the beginning of the covid-19 pandemic among adults from germany date: 2020-09-18 journal: psychiatry res doi: 10.1016/j.psychres.2020.113462 sha: doc_id: 320509 cord_uid: 3a40djjm the covid-19 pandemic is suggested to have a negative impact on mental health. to prevent the spread of sars-cov-2, governments worldwide have implemented different forms of public health measures ranging from physical distancing recommendations to stay-at-home orders, which have disrupted individuals’ everyday life tremendously. however, evidence on the associations of the covid-19 pandemic and public health measures with mental health are limited so far. in this study, we investigated the role of sociodemographic and covid-19 related factors for immediate mental health consequences in a nationwide community sample of adults from germany (n = 4335). specifically, we examined the effects of different forms and levels of restriction resulting from public health measures (e.g. quarantine, stay-at-home order) on anxiety and depression symptomatology, health anxiety, loneliness, the occurrence of fearful spells, psychosocial distress and life-satisfaction. we found that higher restrictions due to lockdown measures, a greater reduction of social contacts and greater perceived changes in life were associated with higher mental health impairments. importantly, a subjectively assumed but not an officially announced stay-at-home order was associated with poorer mental health. our findings underscore the importance of adequate risk communication and targeted mental health recommendations especially for vulnerable groups during these challenging times. the coronavirus disease has recently evolved into a global crisis affecting the physical and mental health of people worldwide. due to the rapid dissemination of the sars-cov-2 virus and its potential deleterious effects for physical health, governments worldwide have imposed different forms and levels of public health measures ranging from physical distancing recommendations to stay-at-home orders to contain an uncontrolled spreading of the sars-cov-2 virus. although being effective in preventing a further dissemination of the coronavirus (nussbaumer-streit et al., 2020) , these measures may have changed peoples" everyday life significantly and may have led to an immediate disruption of self-regulated behavior and a reduction of social connections (e.g. loss of reinforcer and social support, perceived controllability) which may lead to specific mental health problems, especially in vulnerable people (lewinsohn and atwood, 1969; brooks et al., 2020; holmes et al., 2020) . moreover, people are faced with the risk of a potentially life-threatening covid-19 infection, which may trigger feelings of uncertainty, fear, anxiety and even result into social isolation (asmundson and taylor, 2020; mertens et al., 2020) . a few previous studies from different countries worldwide investigated the role of sociodemographic and covid-19 related factors for mental health (gonzález-sanguino et al., 2020; losada-baltar et al., 2020; pierce et al., 2020; tull et al., 2020; wang et al., 2020; see luo et al., 2020 ; vindegaard and eriksen benros, 2020 for a review). their findings suggest that especially women, younger people, as well as individuals with a mental disorder, chronic somatic disease, and predisposing factors for a potentially severe course of covid-19 are at risk for mental health problems during these challenging times. however, studies on the effects of different forms and levels of restrictions resulting from public health measures (e.g., stay-at-home orders, being quarantined or reduction of social contacts) on mental health are scarce. studies from previous epidemics and the current covid-19 pandemic investigated the role of quarantine and related measures for mental health. some of these studies revealed that quarantine was associated with elevated mental health problems (wang et al. 2020b; liu et al. 2012; wu et al. 2009; bai et al. 2004 ). however, these findings were not entirely conclusive, given that other research did not find such associations (wang et al. 2011; zhu et al. 2020; wang et al. 2020a; zhang et al. 2020) . consequently, to adequately inform the public health care system and enable adequate measures to protect from or mitigate adverse mental health effects, the consequences and relevant factors influencing the psychological response to the pandemic and public health measures need to be characterized. in germany, daily infection rates rapidly increased early in march 2020. at that time, each federal state started to implement public health measures (e.g., closure of schools and kindergartens) to prevent a further spread of covid-19. although various measures were implemented all over germany, some measures (e.g. stay-home orders) and the associated degree of restriction for individuals" personal and social life differed between german federal states. the present study was conducted four weeks after all german federal states had implemented public health measures (e.g., minimum distance of 1.5 m to other persons, closure of non-essential shops, such as bookstores, warehouses; see steinmetz et al., 2020) . at the time of the study, the highest rate of covid-19 related death per day in germany was recorded since the outbreak of covid-19 in germany. the present study was aimed at identifying potential predictors for immediate mental health consequences to the covid-19 pandemic and related public health measures in germany. between 17 th april and 15 th may 2020, a cross-sectional study was conducted among 4335 adults (75.8 % women and 24.2% men) from all federal states of germany. participants were aged between 18 and 95 years (m=40.50 years, sd=12.45 years). the study started during the first peak of the corona crisis in germany (highest rate of covid-19 related deaths per day), four weeks after all german federal states had implemented public health measures. participants were recruited via convenience sampling methods (social media, personal contacts, e-mails, etc.) and completed an online survey (soscisurvey.de). all participants provided informed consent. the study was approved by the local ethics committee of the university of marburg. in addition to sociodemographic and covid-19-related variables (see table 1 for an overview), we assessed the following variables related to implemented public health measures: perceived changes in life due to public health measures: participants were asked to rate how much their everyday life had changed due to governmental measures that were taken to contain covid-19 spreading on a 9-point likert-scale (ranging from "not at all" to "very strong") and whether they perceived these changes as positive, neutral, or negative. social distancing: participants were asked to indicate how frequently they currently engage in social contacts with reference to january 2020 (prior to covid-19 outbreak in germany; converted scale: much less, less, unchanged) and whether they are distressed (5-point likert-scale ranging from not stressful at all to extremely stressful) by the restriction of social contacts. restrictions due to public health measures: 14 forms of restriction measures that have been suggested to disrupt self-regulated and psychologically relevant behavior of individuals (steinmetz et al., 2020) were systematically recorded for each of the 16 german federal states on a day by day basis (e.g., prohibition to meeting with others in public places, closure of kindergartens or daycare, prohibition to leave the apartment without reason) by the leibniz institute for psychology information (zpid, germany). each type of restriction was coded as not present (=0), partially (=1) or fully (=2) in place. for each public health measure, we determined the highest level of restriction (i.e., not present, partially or fully in place) within the period prior to the start of the survey. afterwards, the score of each measure was summed up to determine the overall level of personal and social restrictions resulting from public health measures in each federal state. stay-at-home-order: data provided by the zpid were also used to objectively determine which german federal state had announced a prohibition to leave the apartment without reason. perceived stay-at-home order: moreover, participants were asked to indicate whether they assumed that the government of their federal state had imposed a prohibition to leave the apartment without reason. this allowed us to delineate the effect of officially announced and subjectively perceived stay-at-home-orders on psychological outcome measures. the following psychological outcome measures were assessed: depressive symptoms were assessed with the patient health questionnaire-9 (phq-9; kroenke et al., 2001) . generalized anxiety was assessed with the 7-item generalized anxiety disorder scale (gad-7; spitzer et al., 2006; kroenke et al., 2007) , health anxiety with the short mental health during the covid-19 pandemic 8 version of the whitely index (fink et al., 1999; hiller et al., 2002) , moreover, using the respective question of the dsm-5 cidi, participants were asked to indicate whether they had experienced a fearful spell during the last 4 weeks. loneliness was assessed with the 3-item version of the ucla loneliness scale (russell, 1996) . psychosocial distress (e.g., due to financial problems or worries, distress at work, distress resulting from childcare, etc.) was assessed with the stress module of the patient health questionnaire. finally, and as in previous research (see lucas and donnellan, 2012) , general life satisfaction was assessed with a single item ("all things considered, how satisfied are you with your life these days?") and a 11-point likert-scale ranging from 0 (completely dissatisfied) to 10 (completely satisfied). statistical analyses were conducted with spss 26 (spss for windows, ibm). analyses including data provided by the zpid (restrictions by public health measures and officially announced stay-at-home orders) were limited to those participants who reported their zip codes (n=4185). first, linear regressions (adjusted for gender and age) were used to test associations of sociodemographic and covid-19-related factors with psychological outcomes. second, all sociodemographic and covid-19-related variables being significantly associated with outcomes were used as multiple predictors for outcome measures. the alpha level was set at .05. in the present study, 31.1% of the sample exceeded the cutoff score for a potential depression diagnosis (phq-9 ≥ 10), 21.2 % exceeded the cutoff score for a potential anxiety disorder diagnosis (gad-7 ≥ 10), 29.4 % exceeded the cutoff score for health anxiety (wi-7 ≥ 3), 55.2 % reported to be lonely (loneliness ≥ 6), 41.4% of the sample reported mild psychosocial distress (phq stress module scores ranging between 5 and 9), while 26.5 % reported moderate to severe psychosocial distress (phq stress module ≥ 10). 13.1 % of the sample reported having experienced a fearful spell during the last 4 weeks. the mean score of life-satisfaction was 6.42 (sd = 2.31). associations between sociodemographic factors and psychological outcomes are presented in table 1 . female sex, younger age, a lower educational level, being unemployed, being single, living alone, living without underage children and a current or past psychotherapeutic or psychiatric treatment were associated with higher depressive symptomatology. female sex, younger age, a lower educational level, being unemployed, living alone, as well as current or past psychotherapeutic or psychiatric treatment were associated with higher anxiety symptomatology. being unemployed or not working and current or past psychotherapeutic or psychiatric treatment was associated with higher health anxiety. younger age, lower educational level, being unemployed, living alone and current or past psychotherapeutic or psychiatric treatment were associated with higher loneliness. female sex, younger age, lower educational level, living together in a relationship, living with underage children and a current or past psychotherapeutic or psychiatric treatment were associated with higher psychosocial distress. female sex, older age, a higher educational level, being employed, cohabiting with a partner, cohabiting with children, no current or past psychotherapeutic or psychiatric treatment were associated with higher life-satisfaction. being in self-quarantine was associated with higher health anxiety and with fearful spells. however, being quarantined by a local health authority was not associated with any psychological outcome. belonging to an officially announced covid-19 risk group was associated with higher anxiety and depressive symptomatology, health anxiety, fearful spells, higher psychosocial distress, and lower life-satisfaction. having contact to loved ones that belong to an officially announced covid-19 risk group was associated with higher health anxiety and lower loneliness. having a confirmed diagnosis of covid-19 was associated with higher loneliness, while a confirmed diagnosis of covid-19 in loved ones was not associated with any outcome measure. a higher level of restriction due to public health measures was associated with higher loneliness, higher psychosocial distress, and lower life-satisfaction. a stronger reduction of social contacts, higher distress due to restrictions of social contacts, stronger perceived changes in life due to the public health measures and a more negative appraisal of these perceived changes were positively associated with higher anxiety and depressive symptomatology, fearful spells, psychosocial distress and lower life-satisfaction. there was no association (expect for social distancing related distress) of theses predictors with health anxiety. 41.1% of the sample correctly reported that there was no officially announced stay-athome order in their federal state, while 21.8% of the current sample correctly reported to live in a federal state in which government had announced a stay-at-home order. however, 26.6% of the sample reported that there was an officially announced stay-at-home order in their federal state, despite the fact that there was no governmental imposed prohibition to leave the apartment without reasons. 6.6 % of the sample negated that the government has officially announced a stay-at-home order, while their federal state has officially announced a stay-at-home order. there was no association of officially announced stay-at-home orders with psychological outcome measures (see table 1 ). however, perceived stay-at-home orders were associated with higher anxiety and depressive symptoms, fearful spells, higher psychosocial distress, higher loneliness, and lower life-satisfaction (see table 1 ). perceived stay-at-home orders were unrelated to health anxiety. moreover, to test whether perceived stay-at-home orders interacted with officially announced stay-at-home orders in predicting scores on psychological outcome measures an interaction term was included in the regression analysis. the moderation analysis revealed that an officially announced stay-at-home order did not interact with the perceived stayat-home order in predicting mental health outcomes. that is, participants who believed that government had announced a stay-at-home order reported higher scores on psychological outcome measures whether or not government has officially announced stay-at-home orders in their federal state (officially announced x subjectively perceived stay-at-home order interaction, βs = -.028 -.041, or = 1.494, all ps > .05). moreover, negating a stay-at-home order despite the fact that government has announced a stay-at-home order was unrelated to our mental health outcomes (β = -.015 -.010, or = 0.709, all ps > .05). table 2 summarizes the predictors that remained significantly related to the psychological outcomes in multiple regression models. a current or past psychiatric or psychotherapeutic treatment, belonging to a covid-19 risk group and perceived distress related to the restriction of social contacts were significant predictors in all models (see table 2 for detailed information on all significant predictors for the respective outcome measure). the overall models significantly explained between 12.2 % and 64.1 % of variance in psychological outcome measures (see table 2 ), all p-values < .001. in early 2020, governments worldwide started to implement different forms of public health measures ranging from physical distancing recommendations to stay-at-home orders to prevent further spreading of covid-19. for the first time, this study investigated sociodemographic and covid-19 related factors and, specifically, the role of such different types of governmentally imposed lockdown measures for depressive and anxiety symptoms as well as other health outcomes across all federal states of germany. in the present sample, 31.1% exceeded the cutoff score for a potential depression, 21.2 % exceeded the cutoff score for a potential anxiety disorder diagnosis and 13.1 % of the sample reported having had a fearful spell during the past 4 weeks. these data are comparable to the prevalence reported in studies conducted in other countries during the covid-19 pandemic (luo et al., 2020) . consistent with previous studies from countries around the world (see luo et al., 2020; vindegaard and eriksen benros, 2020 for a review), we found that belonging to a risk group for a severe course of covid-19, a current or past treatment due to mental health problems, being unemployed or nonworking, a lower educational level and younger age were associated with negative mental health consequences of the covid-19 public containment measures. moreover, we revealed that a stronger reduction of social contact, stronger perceived changes in life, and a perceived stay-athome order were associated with poorer mental health. in multiple regressions, common factors that remained significantly related to all outcome measures included a current or past treatment due to mental health problems, distress related to contact restriction and belonging to a risk group for a severe course of covid-19. in the present study, we found that a higher level of restrictions due to lockdown measures was associated with more loneliness, higher psychosocial distress and lower life-satisfaction but was not related to anxiety and depressive symptomatology or fearful spells. although the level of restriction due to lockdown measures was not associated with an immediate increase in psychopathological symptoms, more loneliness and higher psychosocial distress might be relevant factors that facilitate or moderate potential negative consequences for mental health. especially loneliness has been associated with an increased risk for several mental disorders and somatic diseases in general (beutel et al. 2017; holt-lunstad et al. 2015; valtorta et al. 2018; luhmann und hawkley 2016) and during the current pandemic (palgi et al. 2020; gonzález-sanguino et al. 2020; luchetti et al. 2020) . for example, recent studies found that loneliness strongly predicted depressive and anxiety symptoms during covid-19-related lockdown measures (palgi et al. 2020; gonzález-sanguino et al. 2020) . thus, reducing loneliness might be an important target for prevention programs in order to mitigate negative mental health consequences during these challenging times (holmes et al. 2020) . moreover, an officially announced stay-at-home order was not related to mental health outcomes. however, about one in four respondents reported to live in a german federal state in which government has imposed a prohibition to leave the apartment without sound reasons (stayat-home order), while objective data indicated that the respective government had not announced such stay-home-order. although there was a stay-at-home order, 6% of the sample negated that there was an officially imposed prohibition to leave the apartment in their federal state. in contrast to the officially announced stay-at-home order, a perceived stay-at-home order was associated with poorer mental health outcomes. the present findings extend preliminary results from a small cross-sectional study in the us (tull et al., 2020) in demonstrating that a perceived stay-at-home order was related to more severe depressive and anxiety symptomatology, greater reported loneliness, more fearful spells, greater psychosocial distress and lower life-satisfaction irrespective of whether a stay-at-home order was officially announced or not. importantly, those persons who were affected by a stay-at-home order but took no notice of this order showed no negative mental health consequences. the present finding indicates that misinformation about official stay-at-home orders might have a negative impact on mental health. for example, recent studies found that insufficient information (gonzález-sanguino et al. 2020) or misinformation ("fake news") on covid-19 (wang et al. 2020b ) was associated with poorer mental health and well-being (ko et al. 2020; chao et al. 2020; gao et al. 2020) . in contrast, receiving information from health professionals or other experts was not associated with negative mental health consequences (ko et al. 2020; chao et al. 2020) . taken together, this suggests that appropriate risk communication during these challenging times of crisis is particularly crucial. thus, it seems important to announce timely, coordinated, transparent and definite instructions in plain language to all persons via official information channels to mitigate confusion, uncertainties, and misinformation regarding public health measures, to prevent negative mental health consequences. the present results should be considered in the light of the following limitations. in the present study, individuals of all ages (18 -95 years) and from all german federal states were recruited. however, as a result of our recruitment method (i.e., convenience sampling methods) older respondents and men were relatively underrepresented in the current sample which limits the generalization of the present results to the general population of germany and other countries. our study exclusively relied on self-report data which might have been subject to memory and recall-biases. moreover, we only assessed internalizing symptoms like depressive or anxiety symptoms, while externalizing symptoms (e.g., anger, aggression, alcohol abuse) might also be affected by public health measures and restrictions (brooks et al., 2020) . the present study makes a significant contribution to the identification of potential risk groups and the impact of public health measures for immediate mental health consequences during the covid-19 pandemic. the current findings suggest that the covid-19 pandemic cause negative consequence for mental health especially in vulnerable groups (e.g. young adults, individuals with a mental disorder) which may need special attention and support by implementing interventions or prevention programs to mitigate long-term consequences for mental health (holmes et al., 2020) . moreover, in our study, there was little evidence that public health measures per se were associated with immediate mental health impairments. nonetheless, such measures might have unfavorable long-term effects on mental health. for example, lockdown measures have been associated with increased psychological distress and loneliness (tull et al. 2020) . in line with vulnerability-stress models, it is plausible to assume that such unfavorable feelings not necessarily relate to immediate mental health impairments, but may increase the risk to develop psychopathological symptoms and mental disorders in the future. most importantly, the present data indicate that people"s subjective perceptions of public health measures (i.e., the appraisal of perceived changes in life resulting from lockdown measures and the reduction of social contacts as negative or stressful) seem to be associated with increased psychopathological symptoms. this data underscores the need for appropriate risk communication to prevent insecurity, fear, and confusion and thus prevent negative mental health consequences. moreover, it might be helpful to develop and implement interventions or prevention programs including positive reappraisal or reframing and recommendations to maintain social contacts (e.g., via social media, video calls) in the face of physical distancing and contact restrictions to mitigate the negative effect of public health measures on mental health. .060*** .059*** .016 .053** 1.347** or: odds rations from logistic regressions; β: standardized beta coefficient; all logistic and linear regressions were adjusted for age and gender; ***p<.001, **p<.01, *p<.05 or: odds rations from logistic regressions; β: standardized beta coefficient; a nagelkerks r squared; ***p<.001, **p<.01, *p<.05 2020. coronaphobia: fear and the 2019-ncov outbreak loneliness in the general population: prevalence, determinants and relations to mental health the psychological impact of quarantine and how to reduce it: rapid review of the evidence screening for somatization and hypochondriasis in primary care and neurological in-patients mental health consequences during the initial stage of the 2020 coronavirus pandemic (covid-19) in spain dimensional and categorical approaches to hypochondriasis multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science. the lancet psychiatry loneliness and social isolation as risk factors for mortality: a meta-analytic review the phq-9: validity of a brief depression severity measure anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection depression: a clinical-research approach we're staying at home". association of selfperceptions of aging, personal and family resources and loneliness with psychological distress during the lock-down period of covid-19. the journals of gerontology. series b, psychological sciences and social sciences estimating the reliability of single-item life satisfaction measures: results from four national panel studies the psychological and mental impact of coronavirus disease 2019 (covid-19) on medical staff and general public -a systematic review and metaanalysis fear of the coronavirus (covid-19): predictors in an online study quarantine alone or in combination with other public health measures to control covid-19: a rapid review. the cochrane database of systematic reviews 4 mental health before and during the covid-19 pandemic: a longitudinal probability sample survey of the uk population. the lancet psychiatry ucla loneliness scale (version 3): reliability, validity, and factor structure a brief measure for assessing generalized anxiety disorder: the gad-7 the zpid lockdown measures dataset for germany psychological outcomes associated with stay-at-home orders and the perceived impact of covid-19 on daily life this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. the authors declare no conflict of interest. all authors report no financial relationships with commercial interests. -.0 38 * key: cord-314014-d9jwy5b6 authors: duan, hongxia; yan, linlin; ding, xu; gan, yiqun; kohn, nils; wu, jianhui title: impact of the covid-19 pandemic on mental health in the general chinese population: changes, predictors and psychosocial correlates date: 2020-08-18 journal: psychiatry res doi: 10.1016/j.psychres.2020.113396 sha: doc_id: 314014 cord_uid: d9jwy5b6 the current covid-19 pandemic is not only a threat to physical health, but also brings a burden to mental health in the general chinese population. however, the temporal change of mental health status due to pandemic-related stress in relation to protective and risk factors to hostility is less known. this study was implemented at two timepoints, i.e., during the peak and the remission of the covid-19 pandemic. 3233 chinese individuals participated in the first wave, and among them 1390 participants were followed in a second wave. the result showed that fear significantly decreased over time, while depression level significantly increased during the second wave compared to the first wave of the survey. younger age, lower-income, increased level of perceived stress, and current quarantine experience were significant predictors of depression escalation. younger people and individuals who had a higher initial stress response tended to show more hostility. furthermore, the use of negative coping strategy plays a potential intermediating role in the stress-related increase in hostility, while social support acts as a buffer in hostility in the general population under high stress. as the whole world is facing the same pandemic, this research provides several implications for public mental health intervention. since december of 2019, china has experienced a dramatic outbreak of a novel coronavirus disease 2019 (covid19) , which rapidly spread in china and abroad. wuhan, the center city of the epidemic, was locked down for 76 days from january 23 to april 8, and many other regions in china initiated first-level responses to major public health emergencies to curtail further disease transmission. since the announcement of global pandemic threat by the world health organization (who) on march 11, 2020, many other countries initiated their lockdowns on their own. only one study explored the change of mental health problem from the initial outbreak phase (end of january) to the epidemic's peak or acute phase (end of february) in the general public (n = 333) (wang et al., 2020b) . however, they could not investigate the temporal change of mental health problems at the individual level because they were not able to identify repeated respondents at the second time interval. a commonly reported phenomenon in the media during this pandemic is an increase in hostility against people from such as medical profession, other nations or domestic ethnic minorities around the world (wikipedia: list of incidents of xenophobia and racism related to the covid-19 pandemic). in laboratory studies, a wide variety of stressors, like physical pain or minor daily hassles have been demonstrated to increase harmful social reactions such as aggression in both animal models and human participants (for reviews, see sprague et al., 2011; takahashi et al., 2018) . however, the role of stress caused by social quarantine and constant low-level threat due to uncertainty during the pandemic and how this might relate to increased hostility is rarely studied. in the present study, hostility is defined as comprising feelings and/or behaviors characterized by anger expression such as aggression, irritability, rage, and resentment (holi, 2003) . in addition, it was proposed that stress per se is less crucial to mental health than coping strategies a person uses in response to stress (compas et al., 2001) . the construct of coping, the cognitive and behavioral strategies to meet the demands of stressful situations, has been considered an important mediator of the stress-emotion relationship (folkman & lazarus, 1988; main et al., 2011) . coping can be described as negative/avoidant (e.g., distraction, withdrawal, wishful thinking, substance use) or positive/approach (e.g., problem-solving efforts, seeking information) (day & livingstone, 2001). moreover, researchers have found that positive/approach coping is generally related with less psychological symptoms, while negative/avoidant coping is associated with more symptoms in the chinese population (ding et al., 2015; zheng et al., 2012) . furthermore, it is important to examine the social factors that might protect an affected population from developing hostility. social support of individuals by family, friends and even institutions have been widely demonstrated to have positive effects on both physical and psychological well-being, and also to have a moderating effect of stress on health, the so-called "stress-buffering hypothesis" (cohen & wills, 1985) . according to this hypothesis, the moderation effect of social support on stress may arise through both processes depending on the amount of social support (main effect) and processes depending on the interaction of the stress level and the amount of social support (buffering effect). the buffering effect of social support, therefore, becomes more crucial as the stress level individuals perceived increases. consistent with stress-buffering hypothesis, we predicted that social support might act as a buffer between stress and hostility. therefore, the first aim of the current study was to explore the effect of the covid-19 pandemic on mental health of a general chinese population sample during the course of acute pandemic activity the peak of the outbreak (january 31 st to february 9 th ) to the epidemic's remission phase (15 th to 28 th of march) at the individual level. the second aim was to examine whether perceived stress level to the covid-19 pandemic would predict an increase in hostility and whether coping strategies would play a potential intermediating role in the relationship between stress and hostility. it was expected that the underlying mechanism between stress and hostility would function through coping strategies, such that higher perceived covid-19 stress would be related with an increased use of negative coping, which, in turn, would lead to more general hostility. the third aim was to identify protective psychosocial factor from the perspective of perceived social support in the relationship between perceived stress and hostility in the general population sample. according to the stress-buffering effect, individuals with high stress level benefit more from social support than individuals with low stress level (cohen & wills, 1985) . therefore, it was expected that social support would act as a protective factor between stress and hostility. this study was conducted from january 31 st to february 9 th (first wave of the survey, t1) and march 15 th to march 28 th (second wave of the survey, t2), which covered the time from the peak of the outbreak to the remission of covid-19 epidemic in central china. as is shown in fig. 1 , at the first timepoint of this study, china was undergoing a difficult period during which the confirmed and suspected cases reached its peak, and pressure on the healthcare system was intensified. there was little information about the causal agents and available treatment methods for the disease. were asked to fill in the questionnaire according to their current situation in a relatively quiet environment to avoid interference as much as possible. they were also informed that their personal information and responses will be kept anonymous and confidential. this study was approved by the ethics committee of peking university. all participants provided electronic informed consent before the commencement of the two waves of survey. the lines indicate case counts per day of confirmed cases in yellow (note the spike of confirmed case on 14 th of february was due to a change in diagnostic criteria from only by test kits to clinical (radiological) diagnosis of patients), suspected cases in blue, recovered cases in green and casualties in red. to assess the perceived stress to the covid-19 epidemic, perceived stress scale during the second wave of the survey. all the questionnaires were described in detail in the following part. the pss10 includes 10 items assessing stress for the past one month during the covid-19 epidemic. this scale was originally compiled by cohen (1983) and the revised chinese version has been demonstrated to have good reliability and validity (yang et al., 2003 ). an example item is "during the outbreak, how often have you felt that you were unable to control the important things in your life". each item is rated from 1 (not at all) to 5 (very much). the average score is calculated by the sum of each item score divided by the total number of items (range: 1~5). the higher the score, the more stressed the respondent is. the pss10 demonstrated good internal consistency (α = .801) in the current sample. the mental health status during the covid-19 pandemic was measured by the the hostility subscale of the scl-90 (derogatis & savitz, 1999 ) was used to measure hostility levels in the second wave. this hostility subscale comprises 6 items such as temper outbursts that you could not control in the past one week, and each item is assessed by a 5-point likert scale (0 = "not at all" to 4 = "all the time"). the average score is calculated by the sum of each item score divided by the total number of items (range: 1~5). an example item is "how often did you get into frequent arguments within the last week". it reflects the respondents' hostility from three aspects: thoughts, emotion and behavior. in the current sample, the internal consistency coefficient is α = .858. coping style has been widely investigated around the world. however, the difference in research aims contributed to various evaluation tools for coping style. in china, one of the main understandings of coping style is defined it as the tendency an individual is used to adopting. based on this, xie (1998) considering the characteristic of "collectivism" in chinese culture, the chinese psss includes not only supports from family and friends, but also supports from others government. for example, "when we need help, our nation's medical forces can be the first to provide help". this scale was used to measure the subjective and perceived social support of participants in the second wave. the degree of support is rated and average score is calculated (range: 1~7), with higher score indicating more perceived social support. the internal consistency of our research is α = .828. all the statistical analysis was conducted by ibm spss statistics, version 24.0 (ibm for the second and third aim, the intermediating role of coping styles and the moderating role of perceived social support on hostility were analyzed by process macro (model 1 and model 4). in these models, we controlled for sex, age, education, monthly income, and quarantine experience (t1 and t2). all continuous variables were standardized and the interaction terms were computed from these standardized scores. the bootstrapping method produces 95% bias-corrected confidence intervals of these effects from 5,000 resamples of the data. confidence intervals that do not include zero indicate effects that are significant (hayes, 2013) . the standard error of the linear regression model is estimated using hc3 as proposed by davidson and mackinnon (1993). demographic description of the respondents who participated in the two waves of the survey (n = 1390) are shown in the to explore predictors of depression level at t2, a hierarchical regression model was used. specifically, for independent variables, depression level and quarantine experience measured in wave 1 were placed in the first step as the controlled variables; demographic variables (i.e., gender, age, education and monthly income), which were all measured in wave 1, were entered in the second regression step; and increase in perceived stress as well as quarantine experience measured in wave 2 were placed in the third step. as table 3 shows, after controlling initial depression level (depression_t1) and initial quarantine experience (quarantine_t1), δpss10 (β from t1 to t2 is associated with higher depression level at t2. quarantine experience at t2 (β = -.063, p < .05) significantly predicted depression at t2, such that respondents who have the recent experience of quarantine reported higher depression level at t2. furthermore, age (β = -0.056, p < .05) and monthly income (β = -0.054, p < .05) were also significant predictors, indicating that younger people and individuals with lower income experience worsening depression symptoms. there was a significantly positive correlation between pss10 at t1 and hostility at t2 (r = .382, p < .001). in the hierarchical model, initial perceived stress and quarantine experience measured in wave 1 were placed in the first regression step; demographic variables (i.e., gender, age, education and monthly income), which were all measured in wave 1, were entered in the second regression step; and quarantine experience measured in wave 2 was placed in the third step. the result (see table 4 ) showed that the level of perceived stress at t1 (β = .366, p < .001) significantly predicts the higher level of hostility at t2. additionally, age (β = -.082, p < .001) negatively predicts the hostility such that younger people show higher hostility in general. the level of hostility at t2 was positively correlated with negative coping (r = .287, p < .001) and negatively correlated with positive coping (r = -.123, p < .001), which provided a precondition for testing the intermediating effect of coping styles of stress-hostility relationship. a mediation model was built in which perceived stress at t1 was treated as a predictor, the level of hostility at t2 as the outcome variable, negative and positive coping as mediators, and demographic variables (gender, age, education, and monthly income) as covariates. this mediation model was tested using the process macro (model 4) developed by hayes (2013) . as reported in table 5 , perceived stress at t2 is negatively correlated with positive coping (β = -.167, p < .001) and positively correlated with negative coping (β = .055, p < .05). furthermore, positive coping at t2 negatively predicted the level of hostility at t2 (β = -.161, p < .001), while negative coping at t2 positively predicted the level of hostility at t2. furthermore, positive coping and negative coping at t2 independently intermediates the relationship between perceived stress at t1 and the level of hostility at t2 (see result in supplementary material). the results of mediation effect are summarized in fig. 3 . to summarize, positive coping negatively intermediates the effect of stress on hostility, while negative coping positively intermediates the effect of stress on hostility. there was a significantly positive correlation between pss10 at t1 and hostility at t2 (r = .382, p < .001). meanwhile, perceived social support at t2 was negatively correlated with the level of hostility at t2 (r = -.208, p < .001). therefore, the process macro (model 1) by hayes (2013) was used to test whether perceived social support at t2 could moderate the relationship of perceived stress at t1 and the level of hostility at t2. as displayed in table 6 , the interaction effect of perceived stress at t1 and perceived social support at t2 could negatively predict the level of hostility at t2 (β = -.081, p < .001). to further explain the interaction effect, the relationship between perceived stress at t1 and hostility at t2 was plotted. as the moderator, the levels of perceived social support at t2 was divided into low (m -sd) and high (m + sd), respectively. the results showed that as the level of perceived social support at t2 reduced from high to low, the predictive effect of perceived stress at t1 on the level of hostility at t2 was gradually strengthened, and β increased from .241 (p < .001) to .402 (p < .001) (see fig. 4) . therefore, perceived social support buffered the relationship between elevated perceived stress and elevated hostility. in the current study, we investigated the temporal change of mental health status in a sample of the chinese population from the peak to the remission phase of the covid-19 pandemic. we found that compared to the peak phase, levels of perceived stress and fear decreased, while depression levels were significantly increased during the remission phase. regression analysis showed that younger age, lower income, higher perceived stress to the covid-19 pandemic as well as current quarantine experience (measured at t2) are risk factors of depression deterioration. furthermore, we found that the younger age and initial perceived stress during the peak phase predict more hostility in its remission phase. our mediation model showed that however, due to the cross-sectional design, these two studies could not clarify whether these symptoms were elevated above the level as when the pandemic occurred. an assessment of hospital employees in china found that compared to a non-segregated sample, the experience of being segregated during sars was associated with high depressive symptoms three years after the epidemic . with a prospective design, our study provided insights for depression development under the epidemic in the general population. individuals who are young, economically disadvantaged, who have been socially isolated or quarantined and who show a strong initial stress response might be particularly at risk for elevated depression in the aftermath of such a pandemic. we found that younger people expressed more hostility in this covid-19 epidemiological situation, which might be due that younger adults adopt ineffective emotion regulation supported by cognitive control (jackson & finney, 2002) . after reviewing data from structural and functional brain imaging, nashiro and colleagues (2012) found that with preserved amygdala in older adults, they show greater prefrontal cortex activity than younger adults while engaging in emotion-processing tasks. furthermore, individuals perceived higher stress of the covid-19 pandemic at the peak of the outbreak predicted more hostility at the remission phase of the epidemic. this is consistent with berkowitz's (1990) however, our mediation model showed that relations between perceived stress and hostility could be accounted for by the coping strategies individuals selected. this is consistent with stress and trauma literature that the association between life stress and psychological adjustment is strongly mediated by coping strategies (runtz & schallow, 1997; tremblay et al., 1999) . positive coping, such as problem-solving efforts, seeking information and cognitive reappraisal, involves focusing on the cause of the stress and attempting to actively do something to mitigate the stress (carver et al., 1989) . individuals with positive coping strategies believe they have more control over the situation and might in turn develop fewer hostile responses to a stressful situation. negative coping, such as denial, withdrawal, wishful thinking and substance use, involves emotion-focused passive coping strategies in an attempt to reduce the emotional stress elicited by a stressful situation. individuals with passive coping believe they have little control over the situation (folkman & lazarus, 1980; , and therefore display more hostility to the environment. furthermore, the relationship between perceived stress and hostility was moderated by social support, which was consistent with the stress-buffering effect that social support has. compared to individuals with lower levels of stress, individuals with higher levels of stress show a more substantial and beneficial influence of social support (cohen & wills, 1985) . our study provides some implications for public mental health. first, it is crucial to develop and implement effective screening procedures at the institutional level to identify risk and resilience factors to provide precise intervention (yang et al., 2010) . in this context, we identified that younger people are at risk of both depression and hostility in the aftermath of the covid-19 pandemic. second, the effect of pandemic-related stress on emotional disturbance (especially depression) suggests the importance of early individualized psychological intervention in the general population, with a focus on individuals who are economically disadvantaged, individuals who have been quarantined and individuals that exhibit high levels of stress. third, positive coping strategies as well as social support should be encouraged even in the context of social distancing. there are some limitations to our study. first, we investigated a chinese sample only to assess the temporal dynamics of mental health during this pandemic, which limits generalizability to other countries. in the same vein, the questionnaires we used here are not for clinical diagnosis and include constructs that capture culturally-dependent phenomenon such as neurasthenia, social support from the government level. second, all the constructs in the current study were assessed by self-report. however, more and more studies reach the consensus that it is the subjective appraisal rather than the stressor itself that has large impacts on mental and physical health (mathur et al., 2016; pascoe & smart richman, 2009 ). third, the retention rate from the first wave to the second wave in our study was low (approximately 43%). the respondents who participated in the two waves were mainly young and well-educated who might also be more physically and psychologically resilient. older and socio-economically disadvantaged people might constitute a population that is more at risk for severe trajectories of the disease and also consequently might be more prone to perceived stress. despite these limitations, our study tracked the psychological change at the individual level during the peak and remission phase of the covid-19 epidemic in china. fear significantly decreased while depression level significantly increased over the course of the pandemic. we identified that younger age, lower income, higher perceived stress, and current quarantine experience are risk factors for depression deterioration. younger age and higher initial stress predicted higher hostility, which was mediated by negative coping style. furthermore, social support can buffer the effect of stress on hostility. our results might provide implications for public mental health intervention. declaration of competing 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coronavirus disease (covid-19) epidemic among the general population in china a longitudinal study on the mental health of general population during the covid-19 epidemic in china the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perception, and altruistic acceptance of risk reliability and validity of the simplified coping style questionnaire self-efficacy, social support, and coping strategies of adolescent earthquake survivors an epidemiological study on stress among urban residents in social transition period life events, coping, and posttraumatic stress symptoms among chinese adolescents exposed to 2008 wenchuan earthquake the multidimensional scale of perceived social support key: cord-292721-954nxptr authors: grey, ian; arora, teresa; thomas, justin; saneh, ahmad; tomhe, pia; habib, rudy abi title: the role of perceived social support on depression and sleep during the covid-19 pandemic date: 2020-09-18 journal: psychiatry res doi: 10.1016/j.psychres.2020.113452 sha: doc_id: 292721 cord_uid: 954nxptr the aim of the present study was to examine the role of perceived social support pertaining to a range of psychological health outcomes amongst individuals undergoing social isolation and social distancing during covid-19. a total of 2,020 participants provided responses to an online cross-sectional survey comprised of validated instruments including the multidimensional scale of perceived social support (mspss), the 7-item generalized anxiety disorder scale (gad-7), the nine item patient health questionnaire (phq-9), the brief irritability test (bite) and the ucla loneliness scale (ucla-ls). individuals experiencing self-isolation had significantly higher rates of depression, irritability and loneliness compared to those who were not. the risk for elevated levels of depression symptoms was 63% lower in individuals who reported higher levels of social support compared to those with low perceived social support. similarly, those with high social support had a 52% lower risk of poor sleep quality compared to those with low social support. social support was found to be significantly associated with elevated risk for depression and sleep quality. the results contribute to our understanding of differential psychological outcomes for individuals experiencing anti-pandemic measures. in the immediate wake of the announcement by the who regarding the covid-19 pandemic, many countries sanctioned a range of measures to protect public health including social distancing and social isolation which helped to avert an increase of covid-19 incidence (nussbaumer-streit et al., 2020) . however, mental health professionals highlighted the possible range of negative mental health effects based on previous epidemic situations (brookes et al., 2020; holmes et al., 2020; li et al., 2020; mahase, 2020; xiang et al., 2020) . unfortunately, whilst such measures may be efficacious for minimizing the physical spread of the virus, social distancing and self-isolation measures are documented risk factors for the onset and exacerbation of mental health issues (holmes et al., 2020) . anti-pandemic measures disrupt social interconnectedness and this is not only associated with an increased risk of psychological difficulties, but has been previously linked to early mortality (holt-lunstad, et al., 2015) . the emerging research related to covid-19 points to an elevated incidence of negative psychological effects amongst healthcare workers (bo et al., 2020) , covid-infected patients (hguyen et al., 2020) as well as the general population (xiao et al, 2020) with anxiety and depression occurring most frequently (wang et al., 2020; gao et al., 2020; tan et al., 2020) . other groups have demonstrated the downstream consequence of covid-19 upon sleep quality (xiao & yhang, 2020) , which is a known driver of the onset and progression of mental health outcomes (baglioni et al., 2011) . to date, the specific factors propelling poorer levels of mental health observed during the current pandemic remain unknown (holmes et al., 2020) . some have suggested increased social media exposure may be partly responsible (gao et al., 2020) whilst others have pointed to the duration of social isolation may be an important factor (brookes et al., 2020; purssell et al., 2020; hawryluch et al., 2004) . one particular topic that has also been the focus of some interest during the current pandemic has been the role of social support and its role as a psychosocial protective factor in relation to mental health difficulties. to date social support has been broadly construed in two ways: perceived social support and received social support (eagle et al., 2019) . perceived social support concerns the subjective evaluation of how individuals perceive friends, family members as available to provide material, psychological and overall support during times of need whereas received support relates to the actual quantity of support received. this distinction between these two types of support is important for two reasons. firstly, perceived social support measures are designed to assess individual perceptions concerning the general availability and adequacy of support and/or global satisfaction with support provided whereas measures of received support targets the specific supportive behaviours that are provided to individuals by their social support networks (eagle et al., 2019) . secondly, a sizeable body of research indicates that perceived social support is only modestly correlated with measures of received support (haber et al. 2007; lakey et al, 2010) . furthermore, existing meta-analytic studies examining the relationship between these two types of support do not support the traditional view that received support is the primary constituent factor in perceived support (haber et al., 2007) . indeed, social cognitive theories in this domain describe cognitive, judgment, and perceptual processes involved in support appraisals and challenge the notion that support perceptions are primarily determined by specific, objectively identifiable events (kaul & lakey, 2003; procidano, 1997) . while there is a strong and well-validated relationship between poorer mental health and low levels of perceived social support (lakey & cronin, 2008; liang, krause, & bennett, 2001) , the relationship between received social support and mental health outcomes appears to be weak (lakey et al., 2010; son, lin, & george, 2008; uchino, 2009) . several recent studies have evaluated the role of perceived social support during the covid-pandemic. higher ratings of perceived social support from family are reported as being associated with lower levels of depression and ptsd levels of depression and ptsd symptoms moreover, medical staff who report higher levels of perceived social support report increased self-efficacy and sleep quality and reduced anxiety and stress (xiao et al., 2020) . thus, increased levels of perceived social support may mitigate the effects of social isolation and social distancing measures (zhang & ma, 2020) . in nonpandemic situations, positive associations between social support and psychological well-being among adults and youth have been documented (peirce et al., 2000) . furthermore, inverse associations have been observed between social support and depression, and tentatively with schizophrenia, bipolar disorder and anxiety disorders (wang et al., 2018) . unfortunately, the role of perceived social support pertaining to mental health and related behaviors during the current pandemic remains largely absent. a better understanding of the role played by perceived social support is therefore crucial amongst individuals experiencing anti-pandemic measures during covid-19 in light of the foregoing discussion, the primary objective of our study was to comprehensively examine the role of perceived social support in relation to depression, anxiety, irritability and sleep quality amongst individuals undergoing social isolation during the covid-19 outbreak. based on the existing literature, we hypothesized that perceived levels of social support would be associated with an increased risk of anxiety and depressive symptoms as well as poorer sleep quality. a total of 2,020 individuals provided consent to participate in the study. demographic information was collected pertaining to age group (years), gender, current living arrangements, family income, social isolation, duration of social isolation (weeks), relationship status, educational level, current occupational status, presence of underlying medical conditions, and whether the person knew somebody personally who had contracted covid-19. this study was conducted in accordance with the declaration of helsinki and was approved by the institutional review board at the first authors university (approval number: lau.sas.ig6.2/apr/2020). all participants indicated their consent after being presented with study-related information. a crosssectional design was utilized and the web link was disseminated through social media platforms and email. survey monkey is an online platform which was used to collect the data online. the mspss is a 12-item scale that measures perceived adequacy of social support from three domains:family, friends, and significant others (zimet et al., 1990) . it has a three factor structure with each subscale comprising four items addressing practical help, emotional support, availability to discuss problems and help in decision making (see table 1 ). there is a special person who is around when i am in need. there is a special person with whom i can share my joys and sorrows. i have a special person who is a real source of comfort to me. there is a special person in my life who cares about my feelings. participants are asked to indicate their agreement with items on a seven-point likert scale, ranging from very strongly disagree to very strongly agree yielding a score range from 12 to 84. scores from 12-48 indicate low social support, scores from 49-68 indicate moderate social support, and scores from 69-84 indicate high social support. several studies indicate that the measure possesses adequate psychometric properties in adults (dambi et al., 2018; laksmita et al., 2020; zimet et al., 1990 ). in the present study, cronbach's alpha coefficient and the intra-class correlation coefficient (icc) for this tool were 0.89 and 0.92, respectively. the gad-7 is one of the most frequently used diagnostic self-report scales for screening, diagnosis and severity assessment of anxiety disorder (spitzer et al., 2006; jordan et al., 2017) . responders are asked to rate the frequency of anxiety symptoms in the last two weeks on a likert scale ranging from 0-3 (0 = not at all, 1 = several days, 2 = more than half the days and 3 = nearly every day). items are summed to provide a total score ranging from zero to 21 yielding a total anxiety score. severity can be determined by the following cut-off scores; 1-4 minimal symptoms, 5-9 mild symptoms, 10-14 moderate symptoms and 15-21 severe symptoms. the gad-7 has been subjected to numerous psychometric evaluations and is reported to have good reliability and validity across different population groups (johnson et al., 2019) . the measure also has good internal consistency (cronbach α = .92) and test-retest reliability is adequate (intra-class correlation = 0.83; spitzer et al., 2006) . in the present study, cronbach's alpha coefficient was high (cronbach α = .91). the phq-9 is the nine-item depression self-report module from the full patient health questionnaire (spitzer, kroenke & williams, 1999) . each item is rated from 0 to 3 based on frequency of each symptom over the previous 2 weeks (0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day). as a severity measure, the phq-9 score can range from 0 to 27). the widely used cutoff scores for the measure are 0-4 (none), 5-9 (mild), 10-14 (moderate), 15-19 (moderately severe) and 20-27 (severe; urtasun et al., 2019) . the initial validation study reported a cronbach's α of 0.89 (kroenke, spitzer & williams, 2001) and subsequent validation studies point to strong reliability and validity of the measure (darlay et al., 2019; mccord & frost, 2020) . in the present study, in the present study, cronbach's alpha coefficient was high (cronbach α = .89). this is a three-item scale assessing loneliness derived from an original 20 item measure (hughes et al., 2004) . the three items on the measure were selected because they showed the highest loading on each respective factor of a three-factor model based on the original 20 item measure (hughes et al., 2004; arimoto & takada, 2019) . responders are asked to indicate how they currently feel in three domains: relational connectedness, social connectedness and perceived self-isolation by indicating hardly ever feel this way (1), some of the time (2) and often (3). scores range from 3 to 9 and yields a category scores of 3 -5 as "not lonely" and people with the score 6 -9 as "lonely". the three-item version is reported to be reliable and valid (hughes et al., 2004) . subsequent studies indicate that the instrument has good validity and reliability (saito et al., 2019; vasser & crosby, 2008) . in the present study, cronbach's alpha coefficient was moderate (cronbach α = .67). this is a five-item measure designed to measure irritability (holtzman et al., 2015) . responders are asked to indicate how often they have felt or behaved during the previous two weeks, including today. each item is rated on a six-point likert scale (1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = very often, 6 = always) yielding a score range from 5 to 30. the scale has demonstrated high internal consistency (cronbach's alpha ≥.88; holtzman et al., 2015) . the instrument is reported to have adequate convergent and concurrent validity (holtzman et al., 2015) . in the present study, cronbach's alpha coefficient was high (cronbach α = .89). this is a self-rated questionnaire which assesses sleep quality and disturbances over a one-month time interval (buysse et al., 1989) . nineteen individual items generate seven "component" scores: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. the sum of the seven subscales are added to derive a global score (0-21) which can be subsequently dichotomized into good (5) and poor (>5) sleep quality. the instrument is reported to have good psychometric properties (buysse et al., 1991; dietch et al., 2016) . all statistical analyses were conducted using stata, version 13. scores for depression (phq-9), anxiety (gad-7), irritability (bite) and loneliness (ucla-ls) and perceived social support (mspss) were visually inspected and were approximately normally distributed. differences between those experiencing quarantine with those who were not were assessed in addition to gender differences on the above measures. to assess the differences between levels of perceived social support in relation to demographics as well as the main variables of interest, chi square and one-way anova were used, as appropriate. a series of pearson's bivariate correlations were performed to assess the relationships between levels of depression, anxiety, perceived social support, loneliness, sleep quality and irritability. a series of multivariate logistic regression analyses were conducted to assess if the independent variable of perceived social support level (using low as the referent) could predict the following three dependent variables: 1) depression (applying a cut point of ≥10 to indicate moderate-severe depression, where <10 was used as the referent); 2) anxiety (applying a cut point of ≥10 to indicate moderate-severe depression, where <10 was used as the referent); 3) sleep quality (using ≤5 as the referent category). three statistical models were created where model 1 was univariate, model 2 was adjusted for age and gender, model 3 was further adjusted for demographic variables (living arrangements, education level, income, living with children under 8 years), duration of lockdown (weeks), if they knew someone personally affected by covid-19 (yes/no), chronic condition (yes/no), as well as depression, anxiety and sleep quality, as appropriate. all covariates were selected a priori during the planning stage of our study and were based on current scientific evidence. p values of < .05 were considered statistically significant for all two-tailed tests. of the 1,655 participants who provided information about self-isolation, 17% (n=277) were not selfisolating at the time of responding and 83% (n=1,378) were. the first step in the analysis involved comparing scores for depression (phq-9), anxiety (gad-7), irritability (bite), loneliness (ucla-ls) and perceived social support (mspss) between those who reported being in quarantine/expiring selfisolation and those who were not. there were no differences between the two groups on scores of perceived social support t(1356) =-.87, p = .32) and on anxiety t(1257) = 1.74, p = .08). significant differences were observed between the two groups with respect to depression t(1315) = 2.27, p = .007), irritability t(1381) = 3.36, p = .001) and loneliness t(1352) = 1.99, p = .04). in summary, those experiencing quarantine had higher scores on depression, irritability and loneliness relative to those not experiencing quarantine. a total of 60% of those experiencing self-isolation (n=827) reported that their mental health had deteriorated since lockdown measures were enforced, while 27% felt it remained the same and just 13% felt it had improved. to test these differences, an independent between-groups anova was implemented in respect of depression scores which yielded a statistically significant result f(1,1094) =182.00, p = .000). to evaluate the nature of these differences between the three groups further, a series of fishers lsd post hoc tests was conducted. the difference between those who felt their mental health had deteriorated and those who felt it had remained the same was significantly significant t(1095) = 6.93, p = .00) as was the difference with those who felt their mental health had improved t(1095) = 7.77, p = .00). in order to test for gender differences across depression, anxiety, irritability, loneliness and social support a series of between-groups anova's were conducted (see table 2 ). in respect of depression, an independent between-groups anova yielded a statistically significant result (f(1,1098) =44.13, p = .000). a significant result was also observed in relation to anxiety (f(1,1069) = 64.21, p = .000), irritability (f(1,1153) = 42.15, p = .000) and perceived social support f(1,1135) = 6.43, p = .011. in summary, females scored higher on measures of depression, anxiety, irritability and social support. demographic characteristics along with the outcomes of interest are presented in table 3 , stratified by level of perceived social support (low, moderate, high). in brief, those aged 25-34 years reported the highest levels of social support (32.61%) compared to 19.15% in 18-24 year olds, and 26.32% in those who were 35 years or older, x 2 (4) = 15.15, p = .004. the mean scores for anxiety, depression, loneliness, irritability and sleep quality were all significantly different across the three levels of perceived social support (p < .001 for all) demonstrating the protective nature of social support systems upon the mental health outcomes of interest as well as sleep and loneliness. (7) 12 (6) 10 (6) <.001 ucla loneliness scale 7 (2) 6 (2) 5 (2) <.001 bite 18 (6) 17 (5) 15 (5) <.001 psqi 9 (4) 8 (3) 7 (4) <.001 data are presented as n (%), or mean (sd). gad = generalized anxiety disorder; phq = patient health questionnaire; psqi = pittsburgh sleep quality index; bite = brief irritability test the correlation matrix is shown in table 4 which highlights the relationships between the two mental health variables (depression and anxiety), sleep quality, loneliness and irritability. briefly, the strongest correlation was observed between depression and anxiety, where r=.72, p<.001. pertaining to social support, significant negative correlations were observed for all variables, with loneliness having the strongest relationship, where r = -.46, p<.001. a series of logistic regression analyses were conducted to assess if social support level could predict either depression, anxiety or sleep quality (see table 5 ). results indicate that perceived social support level was a protective factor for depression and poor sleep quality. the strongest effect size was observed amongst those with high perceived social support in relation to depression, the risk for depression was 63% lower compared to those with low perceived social support (or=.37 [95% ci: .21-.67), after full adjustment of potential confounders. similarly, those with high social support had a 52% lower risk of poor sleep quality compared to those with low social support, after adjustment . anxiety was also significantly associated with perceived social support but after full adjustment (model 3), the relationship was attenuated and became non-significant. researchers have been quick to document the range of mental health effects associated with measures to contain the covid-19 pandemic. to date, elevated levels of depression and anxiety have been reported in the general population in addition to gender differences. it appears from the current that experiencing quarantine results in elevated levels of depression, irritability and loneliness in contrast to those who are not experiencing quarantine. furthermore, females scored higher on measures of depression, anxiety, irritability and loneliness in contrast to males which is in line with recent studies. however, what is also apparent from these emerging studies is that while relatively large numbers of individuals are adversely affected, a substantial number of individuals are not begging the question as to why there is a differential response across individuals. the results of the current study may contribute to a more nuanced understanding of this issue. several existing meta-analytic reviews addressing the relationship between social support and mental health suggest that the presence of such support predicts better mental health functioning and can also be regarded as a protective factor against the onset of mental health difficulties (de silva et al., 2005; harandi, taghinasab, & nayeri, 2017) . more specifically, it has been proposed that high quality social support can enhance resilience to stress and help protect against developing trauma-related psychopathology (ozbay et al., 2007) . in the current study, perceived social support was observed to have significant inverse associations with anxiety, depression, loneliness, irritability and quality of sleep with higher levels of support related to lower scores on measures of these specific outcomes. of particular interest is the relationship between social support and depression as the latter is perhaps the most commonly assessed index of mental health status during the current pandemic. results of the current study indicate that the risk for depression was 63% lower compared to those with low perceived social support (or=.37 [95% ci: .21-.67) when adjusted for age, gender, living arrangement, education level, and presence of chronic condition or illness. a similar pattern was observed in respect of sleep quality with those reporting high levels of social support having a 52% lower risk of poor sleep quality compared to those with low social support (or=.48 [95% ci: .26-.88). these results point to a quite substantial effect of perceived social support both on depression and also in relation to sleep quality which is line with recent meta-analytic reviews which also indicate a robust association between social support and sleep outcomes (kent de grey et al., 2018) . previous research also suggests that perceived social support is a significant predictor of depressive symptoms (alsubaie et al., 2019) . in respect of limitations, the current study focused solely on the relationship between perceived social support and mental health and sleep. whilst the existing literature suggests that perceived social support has a more robust relationship with mental health outcomes than received support, what remains unanswered is the question has to what combination of contextual and intra-individual factors lead to appraisals of social support, whether these be high or low, for individuals experiencing antipandemic measures. in light of research which clearly suggests that received support is only modestly related to perceived support it has been proposed that individuals who report higher levels of perceived social support may have what has been termed a 'positive psychological profile' (uchino, 2009 ) which entails they are more likely to evaluate any form of received social support in a more positive manner. as such, future research investigating the role social support during anti-pandemic measures may benefit from the examination of personality factors such as resilience and coping styles in the context of how individual access and receive support to provide a more complete understanding of perceived social support during a pandemic situation. changes in perceived social support across the duration of the pandemic would also be of interest as previous research suggests that declines in perceived support are 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associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china timely mental health care for the 2019 novel coronavirus outbreak is urgently needed the effects of social support on sleep quality of medical staff treating patients with coronavirus disease 2019 (covid-19) in january and february 2020 in china impact of the covid-19 pandemic on mental health and quality of life among local residents in liaoning province, china: a cross-sectional study psychometric characteristics of the multidimensional scale of perceived social support the authors declare no conflict of interest. key: cord-336942-2mvcyvbl authors: liu, cindy h.; zhang, emily; wong, ga tin fifi; hyun, sunah; hahm, hyeouk “chris” title: factors associated with depression, anxiety, and ptsd symptomatology during the covid-19 pandemic: clinical implications for u.s. young adult mental health date: 2020-06-01 journal: psychiatry res doi: 10.1016/j.psychres.2020.113172 sha: doc_id: 336942 cord_uid: 2mvcyvbl this study sought to identify factors associated with depression, anxiety, and ptsd symptomatology in u.s. young adults (18-30 years) during the covid-19 pandemic. this cross-sectional online study assessed 898 participants from april 13, 2020 to may 19, 2020, approximately one month after the u.s. declared a state of emergency due to covid-19 and prior to the initial lifting of restrictions across 50 u.s. states. respondents reported high levels of depression (43.3%, phq-8 scores ≥ 10), high anxiety scores (45.4%, gad-7 scores ≥ 10), and high levels of ptsd symptoms (31.8%, pcl-c scores ≥ 45). high levels of loneliness, high levels of covid-19-specific worries, and low distress tolerance were significantly associated with clinical levels of depression, anxiety, and ptsd symptoms. resilience was associated with low levels of depression and anxiety symptoms but not ptsd. most respondents had high levels of social support; social support from family, but not from partner or peers, was associated with low levels of depression and ptsd. compared to whites, asian americans were less likely to report high levels across mental health symptoms, and hispanic/latinos were less likely to report high levels of anxiety. these factors provide initial guidance regarding clinical management for covid-19-related mental health problems. the covid-19 pandemic that has upended the lives of individuals worldwide escalated in the u.s. beginning in march of 2020. although research on acute and widescale stressors (e.g., natural disasters), demonstrates severe implications for mental health (kessler et al., 2008) , there is no precedent for understanding mental health effects due to covid-19, as prospective studies investigating the effects of a pandemic are virtually non-existent. in particular, the identification of risk factors associated with depression, anxiety, and post-traumatic stress disorder (ptsd) among u.s. young adults (18-30 years) is urgently needed. comprising more than one-third of the current u.s. workforce, young adults (often referred to as -millennials‖ and -generation z‖) will be a dominant workforce group for the next decade, and our societal functioning depends on how they emerge from the pandemic. understanding their health and well-being during the pandemic is crucial as it sets the stage for later outcomes. certain risk and protective factors are likely to be implicated in pandemic-related mental health. covid-19-related worry (e.g., maintaining employment, getting tested for coronavirus) may be linked to mental health symptoms. the early weeks of the pandemic saw rapid changes in daily routines, with students moving following university closures and attending classes remotely, and for other young adults, transitioning to remote work or facing job loss. these disruptions may put an already vulnerable group at greater risk for mental health challenges (conrad, 2020) . furthermore, loneliness may be particularly prevalent and devastating during the pandemic given directives for social distancing and isolation. those under the age of 25 already show elevated levels of loneliness (domagala-krecioch and majerek, 2013) , and the pandemic may exacerbate these feelings. despite the critical role that social support plays in mitigating the risks to mental health problems, directives on social distancing may impede on one's typical means for obtaining such support. individual resilience, which refers to one's ability to cope with stress, and distress tolerance, which describes one's ability to manage and tolerate emotional distress, may be salient characteristics that protect against the mental health symptoms that follow major stressors. individual resilience is a significant protective factor for depression, ptsd, and general health after natural disasters (kukihara et al., 2014) . findings have generally demonstrated distress tolerance to be associated with lower symptoms of depression and ptsd following tornadoes (cohen et al., 2016) . however, the extent to which these factors are associated with mental health symptoms during a pandemic is unknown. this study sought to identify potential factors that contribute to mental health outcomes among young adults during the covid-19 pandemic. the cares 2020 project (covid-19 adult resilience experiences study, www.cares2020.com) was launched to track the health and well-being of young adults in the u.s. across multiple time points in 2020 and 2021. this present analysis assessed depression, anxiety, and ptsd symptomatology, and psychological experiences including distress tolerance, resilience, social support, and loneliness. we included depression and anxiety as these are common mental health symptoms among young adults (blazer et al., 1994; chen et al., 2019; eisenberg et al., 2007; liu et al., 2019; mojtabai et al., 2016) . we assessed ptsd symptoms given documented high rates of trauma by young adulthood (costello et al., 2002; reynolds et al., 2016; vrana and lauterbach, 1994) ; a concern was that the pandemic would either create and/or exacerbate symptoms related to prior trauma (breslau et al., 2008 (breslau et al., , 1999 brunet et al., 2001) . new items that specifically assessed covid-19specific concerns were also included. the objective of this work is to identify salient psychosocial risks for mental health symptoms and to prioritize intervention targets for addressing mental health symptoms among young adults. the present cross-sectional study assessed potential risk and protective factors for mental health outcomes based on preliminary cares 2020 data obtained from wave 1 data collection (n = 898) conducted from april 13, 2020 to may 19, 2020, approximately one month after the u.s. declared a state of emergency due to covid-19 and prior to the initial lifting of restrictions across 50 u.s. states. eligible participants were young adults aged 18 to 30 years currently living in the u.s. or receiving education from a u.s. institution. participants were recruited online via email list serves, social media, and word of mouth (i.e., list serves and facebook groups for school organizations or clubs, alumni groups, classes, churches). this took place initially through organizations from the new england area before additional list serves from other regions of the u.s. (midwest, south, and west) were targeted. respondents were asked to complete a 30minute online qualtrics survey regarding covid-19-related experiences, risk and resilience, and physical and mental health outcomes. to ensure data quality, human verification and attention checks were implemented throughout the survey; the data was further inspected visually for response irregularities indicative of bots. participants were compensated via raffle in which one out of every 10 participants received a $25 gift card. all procedures were approved by the institutional review board at boston university. binary scores were created after calculating the mean or sum of each measure. rather than relying on the sample characteristics to categorize our data (e.g., mean, median, tertile or quartile split), the determination of the cutoff score was based on standard cutoffs from previous research; when a standard was not available, scale response descriptors to determine the cutoffs. psychological resilience was measured using the 10-item connor-davidson resilience scale (cd-risc-10, connor and davidson, 2003) , which assesses one's ability to cope with adverse experiences. participants indicated how they felt in the past month on a 5-point scale, with 0 indicating -not true at all‖ and 4 indicating -true nearly all the time.‖ sum scores were recoded dichotomously into -high resilience‖ and -low resilience‖ with a cutoff score of 30 or greater. this cutoff score characterizes responses that tended to be -often true‖ and -true nearly all the time,‖ with those endorsing a score ≥30 considered to be at -very high risk with mental disorders‖ (andrews and slade, 2001; kessler and mroczek, 1992) . the distress tolerance scale is a 15-item measure that assesses participants' abilities to withstand and cope with emotional distress (simons and gaher, 2005) . respondents rated personal attitudes towards feelings of emotional distress on a 5-point scale, ranging from 1 (-strongly agree‖) to 5 (-strongly disagree‖), with higher ratings indicating greater distress tolerance. a global mean score of distress tolerance was calculated. we considered the scale descriptors and followed the cutoffs used for the cd-risc, which was also a 5-point scale. as such, scores were dichotomously recoded so that global mean scores less than 4 indicated -low distress tolerance‖ and scores of 4-to-5 indicated -high distress tolerance.‖ perceived social support was measured using the multidimensional scale of perceived social support (mspss, zimet et al., 1988) , in which participants rated perceived emotional support using a 7-point likert scale ranging from 1 (-very strongly disagree‖) to 7 (-very strongly agree‖). this measure includes three subscales assessing perceived support quality from family, friends, and partners. because mean scores greater than 5 reflected responses indicating -mildly agree,‖ -strongly agree,‖ and -very strongly agree,‖ each subscale mean scores were recoded so that scores 5 or greater referred to -high perceived social support,‖ and scores below 5 were referred to as -low perceived social support.‖ instrumental support was assessed through a 4-item subscale of the two-way social support scale (shakespeare-finch and obst, 2011). participants indicated the extent of their received instrumental support based on a 6-point likert scale ranging from 0 (-not at all‖) to 5 (-always‖). items were summed to create a total score with a possible range of 0-to-20. given cutoffs used for the other 5-point scale in our survey and the scale descriptors, a cutoff score with a sum of 16 or greater indicated -high instrumental support,‖ whereas scores lower than 16 indicated -low instrumental support.‖ loneliness was measured using an adapted 3-item version of the ucla loneliness scale short form (hughes et al., 2004) . participants rated lack of companionship, feelings of being left out, and isolation from others on a scale of 1 to 3, with 1 as -hardly ever,‖ 2 as -some of the time,‖ and 3 as -often.‖ a sum score for loneliness was calculated with a total possible range of 3-to-6 and recoded dichotomously; a cutoff score of 6 or greater indicated -high loneliness‖ as used in prior studies (lowthian et al., 2016; tymoszuk et al., 2019) . severity of covid-19 pandemic-related worry was assessed using a newly developed measure consisting of 6 items, which included the following concerns: -having enough groceries during city lockdowns/social distancing protocols‖, -obtaining a covid-19 test if i become sick‖, -getting treated for covid-19 if i contract it‖, -keeping in touch with loved ones during social distancing protocols‖, -maintaining employment during the subsequent economic downturn‖, and -having enough money to pay for rent and buy basic necessities.‖ participants were asked to indicate their level of worry for each item on a scale of 1 to 5, with 1 being -not worried at all,‖ and 5 being -very worried.‖ sum scores were calculated with a total possible range of 6-to-30 and recoded into a dichotomous variable with a cutoff score of 24 or greater as -highly worried.‖ cronbach's alpha for measure items was .70, indicating good reliability. depression was assessed with the 8-item version of the patient health questionnaire (phq-8, kroenke et al., 2009) which assessed frequency of depressive symptoms in the past two weeks on a scale of 0 (-not at all‖) to 3 (-nearly every day‖). sum scores of the phq-8 had a total possible range of 0-to-24 and were recoded dichotomously based on a cutoff score of 10 or higher (wu et al., 2019) . anxiety was assessed with the generalized anxiety disorder scale (gad-7, spitzer et al., 2006) a widely used measure assessing the frequency of anxiety symptoms in the past two weeks on a scale of 0 to 3, with 0 being -not at all‖ and 3 being -nearly every day.‖ sum scores ranged from 0-to-21. following the convention of other studies (plummer et al., 2016) , responses were recoded dichotomously based on a cutoff score of 10 or higher to determine elevated anxiety. the ptsd checklist-civilian version (pcl-c), a validated 17-item measure, was administered to assess ptsd symptoms (weathers et al., 1993) . participants indicated how much they were bothered by problems and experiences in response to stressful life events in the past month, with 1 as -not at all‖ and 5 as -extremely.‖ sum scores of the 17 items were calculated and created into a dichotomous variable with a cutoff score of 45 or greater, based on the psychometric properties for the measure and as suggested by the national center for ptsd (blanchard et al., 1996) . the variables were normally distributed, with predictors indicating acceptable levels of collinearity (vif < 5). to identify potential risk and protective factors of mental health symptoms, three logistic regression models were performed to examine depression, anxiety, and ptsd symptoms as primary outcomes. resilience, distress tolerance, perceived social support, instrumental social support, loneliness, and covid-19-specific worries were entered as predictors in unadjusted models. age, gender, income, and race were entered in each of the three adjusted models. all variables were binary with exception to age and income, which were continuous. two-tailed p-values were used. to guard against type i error, bonferroniadjustments were made to consider the 8 predictors and 4 covariates used in each model (.05/12=.004). our results and interpretations are therefore based on a significance set at a p<.004 (note that the significance in the tables remain unadjusted to provide more rather than less information to the reader). all analyses were performed using spss 25.0. table 1 shows demographic characteristics of our participants and descriptive data on all predictors and outcomes. the sample was racially and ethnically diverse, with 59.6% white, 21.2% asian, 5.3% black, 6.0% hispanic/latino, 0.1% ai/na, 6.2% mixed race, and 1.4% indicating another race. the majority of respondents were women (81.3%), u.s. born (86.3%), employed (66.7%), students (61.3%), and those who earned less than $50,000 per year (82.1%). among those identifying as students, 89.7% were enrolled as full-time and 7.3% were international students. overall, participants scored as having high loneliness (61.5%), low resilience (72.0%), and low distress tolerance (74.1%). at the same time, the majority of respondents reported having high levels of social support (family, partners, peer, and instrumental). finally, 43.3% of our sample had high levels of depression (phq-8 scores ≥ 10), 45.4% had high anxiety scores (gad-7 scores ≥ 10) and 31.8% had high levels of ptsd symptoms (pcl-c scores ≥ 45). table 2 displays the associations between predictors and mental health outcomes in each of the three models adjusted for the age, gender, race, and income. the results described here pertain only to significance set at p < .004 with bonferroni corrections. predictors that were significantly associated with depression, anxiety, and ptsd included loneliness (or range = 1.98 -2.72), covid-19-specific worries (or range = 2.87 -5.05), and distress tolerance (or range = 0.22 -0.42). specifically, those who endorsed high levels of loneliness and worries about covid-19 and low levels of distress tolerance were more likely to score above the clinical cutoffs for depression, anxiety, and ptsd. those with high levels of resilience were less likely to score above the cutoff for depression and anxiety. those with high levels of family support were less likely to score above the clinical cutoff for depression and ptsd (or = 0.46 and 0.44, respectively). instrumental support was negatively associated with depression. no associations were obtained between support from partners and friends. in analyses of associations between covariates and outcomes, age and income were not associated with depression, anxiety, or ptsd. with regard to gender, men who identified as transgender were more likely to report high levels of ptsd (or = 4.20, ci = 1.62 -10.89, p=.003); no differences were observed between men and women. asian americans compared to whites were less likely to report high levels of depression (or = 0.50, ci = 0.33 -0.76, p=.001) and ptsd (or = 0.40, ci = 0.25 -0.64, p<.001). asians americans and hispanic/latinos were less likely to report high levels of anxiety (or = 0.35, ci = 0.24 -0.53, p<.001, or = 0.35, ci = 0.18 -0.68, p=.00, respectively2). our findings highlight major psychological challenges faced by young adults during the initial weeks of the covid-19 pandemic. at least one-third of young adults reported having clinically elevated levels of depression (43.3%), anxiety (45.4%), and ptsd symptoms (31.8%). the rates of depression, anxiety, and ptsd in our study are considerably higher compared to prior studies that have used the same cut points (phq-8 ≥ 10; gad-7 ≥ 10; and pcl-c ≥ 45). year (26.3%; zhang et al., 2011) . the high rates from our sample may reflect ongoing distress, as we measured the symptoms in the weeks following the government directives for closures. young adults may have been particularly distressed in managing school or work responsibilities during this time while having no sense of certainty regarding the pandemic's end. as well, the high rate of mental health concerns among study participants may be partially attributable to the specific characteristics of our sample; given that the study was launched on the east coast, our young adult respondents may have been located at pandemic -hot spots,‖ with proximity to a greater number of covid-19 cases potentially being an added stressor for our sample. strikingly, the majority of respondents reported feeling lonely during the first two months of the pandemic, as well as having low resilience and low ability to tolerate distress. however, the majority reported having social support from family, partners, and peers, as well as instrumental support during this time. we note that the absolute rates of low perceived social support remains seem problematic. for instance, approximately 37% of respondents reported low family support. these findings highlight major psychological challenges currently faced by young adults during the initial weeks of the covid-19 pandemic. our study also identified factors associated with clinical levels of depression, anxiety, and ptsd symptoms. high loneliness and low distress tolerance levels were consistently associated with high levels of depression, anxiety, and ptsd. high levels of resilience were associated with low anxiety. social support from family was associated with low levels of depression, and ptsd symptoms, whereas support from partners or friends were not associated with any mental health outcomes. high levels of instrumental support were associated with low levels of depression. our data is consistent with findings demonstrating loneliness as a risk factor for mental health (banerjee et al., 2020; hawkley and cacioppo, 2010; okruszek et al., 2020) ; this is particularly salient with government directives for social distancing and isolation. feeling cut off from social groups may lead one to feel vulnerable and pessimistic about one's circumstances, altogether producing negative mood states and anxiety (muyan et al., 2016) , that are further heightened during a pandemic. the high levels of reported loneliness in our sample and its association with depression, anxiety, and ptsd symptoms underscore the severity of experiences of young adults during the pandemic. distress tolerance, or one's ability to manage and tolerate emotional distress, was strongly associated low levels of depressive and anxiety, and ptsd symptoms; individual resilience was associated with low levels of depression and anxiety symptoms, but not ptsd. individual resilience, which encompasses personal competence and trust in one's instincts (connor and davidson, 2003) , has been associated with low levels of depression, anxiety, and ptsd symptomatology after disasters (blackmon et al., 2017) . one's perceived ability to tolerate negative or aversive emotional and/or physical states may be more protective than the personal qualities that comprise psychological resilience, especially for those experiencing symptoms of ptsd during a pandemic. the pandemic is worldwide stressor without a foreseeable endpoint, and the effects of the pandemic cannot be controlled by a single individual. furthermore, the pandemic simultaneously impacts various domains (e.g., financial, relational, and health) with this stress potentially exacerbating the sensations associated with ptsd symptoms. as such, psychological resilience that is typically associated with overcoming setbacks may not be sufficient for protecting against ptsd symptoms within the first several weeks of a widespread pandemic. interventions that target distress tolerance, such as mindfulness-based interventions, may be more effective than cognitive interventions targeting core beliefs about the self especially for those with ptsd symptoms (nila et al., 2016) . longitudinal approaches would help to examine this possibility further. emotional support from family but not from friends and significant others was associated with low levels of depression and ptsd. friends and significant others may have or are perceived to have less capacity to validate other's emotional experiences during a pandemic, considering that they may be young adults who are experiencing similar struggles. emotional support provided by family may be more stable and coupled with the provision of material resources that young adults may still receive from parents. our findings are consistent with prior work showing that family support but not friend and partner support mediates the effects of stress on health (lee et al., 2018) . family support may be more meaningful in providing reassurance to young adults, considering the possible concrete needs during the pandemic. instrumental support, or tangible assistance, may be an important factor for the mental health of young adults during the immediate weeks of the covid-19 pandemic onset given that many were faced with acute disruptions, such as unemployment, financial stress, and relocation following university campus closures. however, instrumental support was not significantly associated with any of the outcomes after adjusting the p-value to .004. additional research is needed to clarify the respective roles on both emotional and instrument support given variations in their potential effects on depression, anxiety, and ptsd. our newly developed covid-19 worries measure uniquely predicted mental health symptoms, underscoring how the specific features of this pandemic give rise to acute stress. the stress resulting from lifestyle changes due to features of covid-19 itself may lead to greater mental health concerns distinct from the endorsement of other risks. our analyses showed that the six items in our measure were reliable and the total subscale score was significantly associated with the symptoms assessed in this study; however, additional work is required to determine the validity of this measure. in general, asian americans were less likely to report high levels of mental health symptoms compared to whites, with hispanic/latino respondents also being less likely to report high anxiety. asian and latino immigrants compared to those who are born in the u.s. are less likely to endorse psychological distress (dey and lucas, 2006; takeuchi et al., 2007) . it is possible that other experiences such as ethnic identity, social networking, and family cohesion serve as a protective factor for mental health, especially for non-u.s. born participants (leong et al., 2013) . the under-recognition of distress symptoms may also be possible among ethnic minorities (liu et al., 2020) . although our sample size of gender minorities was small, men who identified as transgender were more likely to report a high level of ptsd symptoms, consistent with prior research (reisner et al., 2016; shipherd et al., 2011) . greater attention to gender differences in mental health symptoms as well as a deeper study regarding the specific experiences faced by racial/ethnic and gender minorities during pandemic is warranted. the cross-sectional design limits our ability to infer causality involved in leading to mental health problems. we used a convenience sample, and caution must be taken in the generalizability of our findings to the broader population of young adults in the u.s. given the uneven sampling of subgroups. the reliance of self-report itself has limitations, such that it may be prone to misinterpretation. future analyses with the anticipated waves of data collection will enable us to examine the association of our predictors to outcome measures of mental health and to adjust for additional confounds. as well, we will have an opportunity to examine potential moderation effects to understand whether outcomes vary by circumstances or individual characteristics, such as socioeconomic capital, social support type, distress tolerance, and resilience. to our knowledge, our study is the first prospective cohort study to assess mental health outcomes and risk and resilience factors in u.s. young adults during the first several weeks of the covid-19 pandemic. in our study, one in three u.s. young adults reported clinical cut-off symptoms of depression, anxiety, and ptsd as well as high levels of loneliness. we present new evidence that signifies the roles of loneliness, distress tolerance, family support, and covid-19 worries on mental health outcomes during the first month of the covid-19 pandemic. mental health interventions should incorporate these constructs to help mediate the impact of covid-19 on adverse mental health status among u.s. young adults. interpreting scores on the kessler 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traumatic events in a transgender sample: frequency and associated symptoms the distress tolerance scale: development and validation of a self-report measure a brief measure for assessing generalized anxiety disorder: the gad-7 immigration-related factors and mental disorders among asian americans cross-sectional and longitudinal associations between receptive arts engagement and loneliness among older adults prevalence of traumatic events and post-traumatic psychological symptoms in a nonclinical sample of college students annual convention of the international society for traumatic stress studies one year later: mental health problems among survivors in hard-hit areas of the wenchuan earthquake the multidimensional scale of perceived social support support for this manuscript was provided through the national science foundation key: cord-354661-wls1rd7d authors: suen, yiu-tung; chan, randolph chun ho; wong, eliz miu yin title: effects of general and sexual minority-specific covid-19-related stressors on the mental health of lesbian, gay and bisexual people in hong kong date: 2020-08-03 journal: psychiatry res doi: 10.1016/j.psychres.2020.113365 sha: doc_id: 354661 cord_uid: wls1rd7d the impact of covid-19 on mental health has begun to be widely recognized. while the mental health of socially marginalized groups has been examined, there is an absence of studies on how the mental health of lesbian, gay and bisexual (lgb) people have been affected. 857 lgb people in hong kong participated in a community-based survey study. over one-fourth of them met the criteria for probable clinical depression (31.5%) and generalized anxiety disorder (27.9%). besides general stressors, we identified sexual minority-specific stressors during the pandemic. 4.2% of the participants indicated that they had frequently experienced family conflict related to sexual orientation. one-third responded that they had largely reduced connection to the lesbian, gay, bisexual and transgender plus (lgbt+) community (34.7%). the results showed that sexual minority-specific covid-19-related stressors significantly contributed to the variance explained in depressive and anxiety symptoms, beyond the contribution of general covid-19-related stressors. since lgb people are particularly vulnerable to poor mental health during the covid-19 pandemic, lgb people-targeting organizations need to understand more about family, space and privacy concerns in order to provide better support, and lgb safe spaces and shelters may be needed as a policy response. the impact of the covid-19 pandemic on mental health has begun to be widely recognized. fear of getting infected with covid-19 (tzur bitan et al., 2020) , stay-at-home orders, disruptions to daily routines, financial worries (tull et al., 2020) , disruption of lives and work , loneliness and distress , and disruption to mental health services are found to be among the many factors that contribute to poor mental health uniquely in the covid-19 pandemic. in addition to the mental health of patients with confirmed covid-19, the mental health of people around them, such as parents of hospitalized children (yuan et al., 2020) , has also been affected. the mental health of medical doctors, nurses and other staff (chen et al., 2020; elbay et al., 2020; joob and wiwanitkit, 2020; lu et al., 2020; wu et al., 2020; xu et al., 2020) has also been quite rightly given a lot of attention. the mental health of particularly vulnerable groups such as the elderly population (meng et al., 2020) , people experiencing homelessness and refugees (júnior et al., 2020) has also been studied. however, the lives and mental health of lesbian, gay and bisexual (lgb) people during covid-19 have not been studied. as a population, lgb people have a higher prevalence of mental disorders than heterosexual people (meyer, 2003) . minority stress theory proposes that sexual minority health disparities can be explained in large part by stressors induced by a hostile, homophobic social environment, in which lgb people have to live with harassment, maltreatment, discrimination and victimization (frost et al., 2015; meyer, 2013) . it is reasonable to expect that during covid-19, lgb people have been experiencing stressors that are unique to their sexual orientation. an online survey with 1,051 us men who have sex with men (msm) found that the pandemic brought adverse impact to the participants' general wellbeing, social interactions, money, food, drug use and alcohol consumption (sanchez et al., 2020) . half had fewer sex partners and most had no change in condom access or use. some reported challenges in accessing hiv testing, prevention and treatment services. compared to older msm, those aged 15 -24 years were more likely to report economic and service impacts. united nations human rights office (un news, 2020) and regional and local non-governmental organizations have also raised the importance of understanding the impact of the pandemic on sexual and gender minority (e.g. ilga, 2020; lgbt foundation, 2020; madrigal-borloz, 2020; sf lgbt center, 2020) . we thus hypothesize that there are sexual minority-specific covid-19-related stressors. in this paper, we particularly focus on examining two of them. first, lgb people may experience family conflict related to their sexual orientation. during the covid-19 pandemic, social distancing measures and stay-at-home orders may mean lgb people have to stay at home more often than before, and home may not be necessarily a friendly environment for them. this is particularly pertinent as we are studying lgb people in hong kong. previous studies have highlighted that fewer chinese lgb people have come out of the closet as compared to their north american counterparts (kong, 2010; suen & wong, 2017) . it is possible that they may face intense pressure from family for their non-heterosexuality (kong, 2016; tang, 2011) because of the social distancing guidelines during covid-19. second, lgb people may experience reduced connection to the lesbian, gay, bisexual and transgender plus (lgbt+) community during the covid-19 pandemic. connection to lgbt+ community has been shown as an important resilience resource for sexual minority individuals (frost and meyer, 2012) . lgbt+ community connection can provide them with access to affirming social network and support, which is associated with fewer psychological distress (mcconnell et al., 2018) and better well-being (frost and meyer, 2012) . nevertheless, due to the implementation of social distancing restrictions, sexual minority people may have fewer access to lgbt+ community during the covid-19 pandemic. such reduced lgbt+ social support may adversely impact their mental health (mcconnell et al., 2015; snapp et al., 2015) . the present study investigated the mental health of lgb people in hong kong during the covid-19 pandemic. it was estimated in a random telephone survey study (yeo and chu, 2018) that around 4% of the population in hong kong identified as homosexual or bisexual. as reported in the hong kong mental morbidity survey (lam et al., 2015) , the one-week prevalence of icd-10 diagnoses of common mental health disorders in the general hong kong population was 13.3%, with mixed anxiety and depressive disorder being the most common disorder (6.9%). in a recent study conducted among lgb people in hong kong, chan and colleagues found that around one-quarter of the lgb participants met the criteria for probable clinical depression (28.9%) and generalized anxiety disorder (24.1%) during pre-pandemic times. compared with another local study (mental health association of hong kong, 2017) which showed that 14.6% of the general public met the criteria for probable clinical depression, lgb people in hong kong were at greater risk of clinical depression. building upon earlier research, this study aimed to (1) examine covid-19-related stressors and mental health conditions among lgb people in hong kong during the pandemic, (2) compare the levels of general and sexual minority-specific covid-19-related stressors among subgroups of lgb people, and (3) estimate the effects of general and sexual minority-specific covid-19related stressors on depressive and anxiety symptoms. we hypothesized that general covid-19related stressors would be positively related to depressive and anxiety symptoms. in addition, it was hypothesized that sexual minority-specific covid-19-related stressors (i.e., family conflict related to sexual orientation and reduced connection to lgbt+ community) would be positively related to depressive and anxiety symptoms above and beyond general covid-19-related stressors. the study was approved by the research ethics committee of the corresponding author's institution. data collection was conducted in may 2020. participants recruited through lgb community organization, online postings distributed to lgb-related listservs, and lgb social media. participants were included if they (1) were 16 years of age or above, (2) have a gender identity that is consistent with their sex assigned at birth, (3) live in hong kong, and (4) are able to read and understand chinese. individuals who were interested in the study were directed to an online survey platform. they were asked to provide informed consent prior to study participation. a gift voucher of hk$50 (about us$6.4) was provided to each participant in order to compensate for the time they spent on completing the questionnaire. a total of 857 lgb people participated in the study. around 56.1% of the participants were female and 43.9% were male. most of them identified as gay or lesbian (61.1%), 32.2% identified as bisexual or pansexual, and 6.7% identified as others (e.g., queer, asexual, questioning, etc.). more than half of them were aged 16 -25 (55.0%), whereas 33.6% were aged 26 -35 and 11.4% were aged 36 or above. the majority of lgb participants completed bachelor's degree or above (73.7%). half of them were in employment (54.1%), 39.8% were students, and 6.1% were not in employment. around 39.1% had a monthly personal income of below hk$5,000 (around us$645), followed by those with a monthly personal income of hk5,000 -hk$19,999 (around us$645 -us$2,580) (28.0%) and hk$20,000 (around us$2,580) or above (32.9%). half of the participants were single (47.6%), 49.4% were in an exclusive relationship, and 3.0% were in an open relationship. most of them lived with family members, partners, and/or friends (92.3%) whereas 7.7% lived alone. table 1 shows the demographic background of the participants. participants were first required to report their gender, sexual orientation, age, education level, employment status, monthly personal income level, relationship status, and living arrangement. for general covid-19-related stressors, participants were asked to indicate to what extent they had experienced worries and actual problems with their health and financial status during the covid-19 pandemic on a 5-point likert scale from 1 (not at all) to 5 (to a large extent). specifically, they were asked to respond to the following items: (1) "to what extent are you worried about your health condition during the covid-19 pandemic?" (health worries), (2) "to what extent are you worried about your financial situation during the covid-19 pandemic?" (financial worries), (3) "to what extent is your health condition affected by the covid-19 pandemic?" (actual health problems), and (4) "to what extent is your financial situation affected by the covid-19 pandemic?" (actual financial strain). higher scores indicate higher levels of health/financial worries and problems. in addition, disruption in daily routine and reduced social contact were measured by the following items: "how often have your daily routine been disrupted during the covid-19 pandemic?" and "how often have you reduced social contact with your friends during the covid-19 pandemic?" respectively on a 5-point likert scale from 1 (never) to 5 (always). for sexual minority-specific covid-19-related stressors, participants were asked to assess their family conflict they had experienced ("how often have you experienced family conflict related to your sexual orientation during the covid-19 pandemic?") and lgbt+ community connection ("how often have you reduced connection to the lgbt+ community during the covid-19 pandemic") on a 5-point likert scale from 1 (never) to 5 (always). depression was assessed using the 9-item patient health questionnaire (phq-9) (kroenke et al., 2001) . participants were asked to indicate the frequency they had experienced different depressive symptoms over the previous 2 weeks on a 4-point likert. scale from 0 (not at all) to 3 (nearly every day). a sample item includes "little interest or pleasure in doing things". the cronbach's alpha of the scale in this study was 0.90. a probable clinical depression is indicated by a cut-off score of 10 or above on the total score. the phq-9 has a sensitivity of 88% and a specificity of 88% for the diagnosis of major depressive disorder when using 10 as the cut-off score (kroenke et al., 2001) anxiety was assessed by the 7-item generalized anxiety disorder (spitzer et al., 2006) . participants were asked to indicate the frequency they had experienced different anxiety symptoms over the previous 2 weeks on a 4-point likert scale from 0 (not at all) to 3 (nearly every day). a sample item includes "feeling nervous, anxious or on edge". the cronbach's alpha of the scale in this study was 0.94. a probable diagnosis of generalized anxiety disorder is indicated by a total score of 10 or greater. the gad-7 has a sensitivity of 89% and a specificity of 82% for the diagnosis of generalized anxiety disorder at this cut-off score (swinson, 2006) . frequency statistics were performed to examine the levels of general and sexual minorityspecific covid-19-related stressors among lgb people. independent sample t-test and one-way analysis of variance (anova) with bonferroni correction for multiple comparisons were conducted to investigate whether or not the levels of general and sexual minority-specific covid-19-related stressors varied by demographic characteristics (i.e., gender, sexual orientation, age group, and monthly personal income level). hierarchical multiple regression was conducted to estimate the effects of general and sexual minority-specific covid-19-related stressors on depressive and anxiety symptoms. the demographic variables (i.e., gender, sexual orientation, age group, education level, employment status, monthly personal income level, relationship status, and living arrangement) were dummy-coded and entered in block 1. general covid-19-related stressors were included in block 2 for controlling for demographic variables. sexual minority-specific covid-19-related stressors were included in block 3 to examine whether they would predict depressive and anxiety symptoms above and beyond general covid-19-related stressors. to examine whether or not sexual minority-specific covid-19related stressors moderate the effect of general covid-19-related stressors on mental health, 12 interaction terms (6 general stressors × 2 sexual minority-specific stressors) were included in the final block of the models. all continuous predictor variables were mean-centered prior to the computation of interaction terms and being entered into the regression (cohen, cohen, et al., 2003) . if the interaction terms were significant, simple slope analyses were conducted to interpret the relationship between general stressors and mental health at one sd above and one sd below the mean of sexual minority-specific stressors (aiken and west, 1991) . the above analyses were conducted using spss 25.0. more than half of the lgb people reported moderate-to-high levels of worry about their health (63.0%). around 15.5% of them indicated that their health condition had been affected to a moderate-to-large extent during the covid-19 pandemic. in addition, 57.9% of the participants reported moderate-to-high levels of worry about their financial situation, whereas 44.2% indicated that their financial situation had been affected by the pandemic to a moderate-to-large extent. around half of the participants indicated that their daily routine had often or always been disrupted (56.2%) and they had often or always reduced social contact with friends (59.6%) during the covid-19 pandemic. as to sexual minority-specific stressors, around 4.2% of the participants indicated that they had often or always experienced family conflict related to sexual orientation during the covid-19 pandemic. one-third of them responded that they had often or always reduced connection to the lgbt+ community (34.7%). more than one-fourth of the lgb people met the criteria for probable clinical depression (31.5%) and generalized anxiety disorder (27.9%). independent sample t-test and anova were conducted to examine the gender and sexual orientation differences in levels of covid-19-related stressors and mental health (see table 2 ). the results showed that female participants were more likely to reduce social contact with friends (t = -3.65, p < .001) during the covid-19 pandemic than their male counterparts. gay men and lesbians showed significantly lower levels of depressive symptoms than those who identified as bisexual, pansexual, and other sexual orientations (f (2, 854) = 6.73, p = .001). there were age differences in actual financial strain (f (2, 854) = 9.07, p < .001), disruption in daily routine (f (2, 854) = 7.37, p = .001), and reduced connection to the lgbt+ community (f (2, 854) = 6.65, p < .001). people aged 16 -25 years were more likely to experience financial strain and report disruption in daily routine during the pandemic, whereas those aged 36 or above were most likely to report reduced connection to the lgbt+ community. it was also found that those who were 16 -25 showed significantly higher levels of depressive symptoms (f (2, 854) = 7.76, p < .001) and anxiety symptoms (f (2, 854) = 6.71, p = .001), that their older counterparts. in addition, lgb people from different income groups reported significantly different levels of financial worries (f (2, 854) = 16.23, p < .001), actual financial strain (f (2, 854) = 39.55, p < .001), and disruption in daily routine (f (2, 854) = 9.95, p < .001). specifically, people with a monthly personal income of below hk$5,000 showed significantly higher levels of financial worries, actual financial strain, and disruption in daily routine during the covid-19 pandemic. lgb people who had a monthly personal income of below hk$5,000 also reported significantly higher levels of depressive symptoms (f (2, 854) = 10.18, p < .001) and anxiety symptoms (f (2, 854) = 7.72, p < .001), that those from other income groups. hierarchical multiple regression was used to determine stressors associated with depressive symptoms. the results showed that lgb people who had a monthly personal income of hk$20,000 or above showed significantly lower levels of depressive symptoms than those with a monthly personal income of below hk$5,000 (β = -0.17, p = .008). compared with those who were single, lgb people who were in an exclusive relationship showed lower levels of depressive symptoms (β = -0.11, p = .002). it was found that general covid-19-related stressors were positively related to depressive symptoms in lgb people, adjusting for demographic characteristics. in particular, financial worries (β = 0.12, p = .01), actual health problems (β = 0.18, p < .001), and reduced social contact with friends (β = 0.10, p = .003) were positively predictive of depressive symptoms. as shown in table 3 , sexual minority-specific covid-19related stressors explained significant variance in depressive symptoms above and beyond general covid-19-related stressors (∆r 2 = .01, ∆f = 6.25, p = .002). family conflict related to sexual orientation was positively predictive of depressive symptoms (β = 0.11, p = .001), after controlling for general covid-19-related stressors. finally, we examined whether sexual minority-specific covid-19-related stressors moderated the effects of general covid-19related stressors on depressive symptoms. there was a significant interaction effect of actual health problems and family conflict related to sexual orientation (β = 0.14, p = .002). the results of simple slope analysis indicated that actual health problems were only related to higher levels depressive symptoms among lgb people who were frequently exposed to family conflict related to sexual orientation (β = .26, p < .001). for those who were rarely involved in family conflict related to sexual orientation, actual health problems were not significantly related to depressive symptoms (β = .05, p = .30). in addition, regression analysis was conducted to examine stressors associated with anxiety symptoms. it was shown that lgb people who had a monthly personal income of hk$20,000 or above reported significantly lower levels of anxiety symptoms than those who had a monthly personal income of below hk$5,000 (β = -0.17, p = .01). lgb people who were in an exclusive relationship had lower levels of anxiety symptoms compared with those who were single (β = -0.09, p = .02). the results also indicated that several general covid-19-related stressors, including health worries (β = 0.09, p = .02), financial worries (β = 0.10, p = .04), actual health problems (β = 0.11, p = .002), disruption in daily routine (β = 0.10, p = .004), and reduced social contact with friends (β = 0.12, p = .001) were positively associated with anxiety symptoms. consistent with our hypothesis, sexual minority-specific covid-19-related stressors significantly contributed to the variance explained in anxiety symptoms, beyond the contribution of general covid-19-related stressors (∆r 2 = .01, ∆f = 4.62, p = .01). family conflict related to sexual orientation was positively related to anxiety symptoms (β = 0.10, p = .003). no significant interaction effects between general stressors and sexual minority-specific stressors were found (ps > .05). this paper adds to the understanding of mental health of particularly vulnerable social groups during the covid-19 pandemic. while previous research studied the mental health of the elderly population (meng et al., 2020) , people experiencing homelessness and refugees (júnior et al., 2020) , this study expands current understanding by studying the mental health of lgb people in hong kong in the covid-19 pandemic. as shown in the results, more than one-fourth of the lgb people met the criteria for probable clinical depression (31.5%) and generalized anxiety disorder (27.9%) during the covid-19 pandemic. in a previous study conducted among lgb people using the same measures employed in this study, chan and colleagues (2020) found that the prevalence of probable clinical depression and generalized anxiety disorder in lgb people in hong kong was 28.9% and 24.1% respectively during prepandemic times. the current findings indicated that the depressive and anxiety symptoms of lgb people were even more pronounced during the covid-19 pandemic, which warrants further attention and targeted intervention. in addition, the present study showed that lgb people who were younger and with a lower socioeconomic status reported a greater disruption in daily routine and a higher level of actual financial strain. these subgroups within the lgb populations were particularly vulnerable to the negative impact brought by the covid-19 pandemic. social and financial support to those lgb people who have been struggling during the pandemic is much needed. this study also examined the effect of general covid-19-related stressors on depressive and anxiety symptoms among lgb people in hong kong. the findings revealed that actual health problems and reduced social contact with friends were vital factors affecting their mental health. lgb people who had health problems and reduced social contact with friends during the covid-19 outbreak were likely to show higher levels of depressive and anxiety symptoms. most importantly, we identified sexual minority-specific covid-19-related stressors among lgb people. one-third of the respondents indicated that they had largely reduced connection to the lgbt+ community during the pandemic. it is plausible that the enforcement of social distancing guidelines prevented sexual minority people from socializing in lgbt+ spaces (such as bars and saunas). surprisingly, only a small proportion of lgb people (4.2%) had frequently experienced family conflict related to sexual orientation. this might be due to the fact that very few of them disclosed their sexual orientation in chinese families, as revealed in previous studies (kong, 2010; suen and wong, 2017) . family conflict related to sexual orientation appeared to be rare, but when it occurred, it posed a severe threat to the mental health of lgb people. our results showed that family conflict related to sexual orientation significantly contributed to the variance explained in depressive and anxiety symptoms, beyond the contribution of general covid-19-related stressors. family conflict also moderated the association between actual health problems and depressive symptoms, such that the negative effect of actual health problems on depressive symptoms was stronger among those who were frequently exposed to family conflict related to sexual orientation. not only have they been suffering from health, social and financial risks posed by the covid-19 pandemic, they have also been facing additional stressors unique to their sexual orientation, which further exacerbates their mental health problems. the findings are significant and bear important implications for mental health support and service provision. organizations that work with lgb people need to understand more about issues of family, space and privacy concerns in order to better support lgb people during the covid-19 (huang et al., 2020) . it can be a very challenging issue to deal with as staying at home may be the only option for many lgb people and there may not be a way out. it is likely that either domestic violence against lgb people, especially lgb youth, may increase, or that lgb homelessness (keuroghlian et al., 2014) may result when such family conflict related to sexual orientation becomes unbearable. lgb safe spaces and shelters may be needed as a policy response as a result of covid-19 (gorman-murray et al., 2014) . organizations that provide support for covid-19 and mental health also need to understand more about sexual minorityunique stressors in order to provide lgb-culturally competent mental health care support (burgess et al., 2007; israel et al., 2011) . while the present study provides a timely understanding of how the mental health of sexual minorities had particularly been impacted by the covid-19 pandemic, interpretation of the findings must be made with caution. first, the study was conducted among a non-probability sample of lgb people. the sample was disproportionately young and had lower income level. although they might be more vulnerable to the impact of the covid-19 pandemic, the sample could have biased the prevalence of mental health problems reported and thus the findings might not be generalizable to the entire lgb population in hong kong. second, the study was based on a cross-sectional design which did not allow us to establish causality between the variables examined in the study. longitudinal work is needed to determine the effects of covid-19 on sexual minorities in long run. third, single-item measures were used to assess the covid-19related stressors due to the absence of validated scales. although the items had good face validity, future studies should attempt to develop and utilize psychometrically sound measures for assessing covid-19-related stressors. to our knowledge, this study is the first published work on the effects of covid-19 on the mental health of sexual minorities. our findings help inform how the lives of lgb people in hong kong were affected by the covid-19 outbreak. compared with previous research, the results apparently revealed that the depressive and anxiety symptoms of lgb people were elevated during the covid-19 pandemic. consistent with our hypothesis, the data showed that sexual minority-specific covid-19-related stressors explained significant variance in depressive and anxiety symptoms above and beyond general covid-19-related stressors. timely and appropriate interventions are needed to address the mental health disparities in sexual minority individuals during and after the covid-19 pandemic. this research is supported by the general research fund (14607717) -0.02 actual financial strain × reduced connection to lgbt+ community -0.01 (0.15) -0.003 0.10 (0.14) 0.03 disruption in daily routine × reduced connection to lgbt+ community 0.16 (0.14) 0.04 0.04 (0.13) 0.01 reduced social contact with friends × reduced connection to lgbt+ community -0.14 (0.14) -0.04 -0.09 (0.13) -0.03 note. * p < .05, ** p < .01, *** p < .001 multiple regression: testing and interpreting interactions effects of perceived discrimination on mental health and mental health services utilization among gay, lesbian, bisexual and transgender persons bisexual individuals are at greater risk of poor mental health than lesbians and gay men: the mediating role of sexual identity 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hong kong: a 20-year review of public attitudes towards homosexuality and experiences of discrimination self-reported by gay men the gad-7 scale was accurate for diagnosing generalised anxiety disorder conditional spaces: hong kong lesbian desires and everyday life, queer asia psychological outcomes associated with stay-at-home orders and the perceived impact of covid-19 on daily life fear of covid-19 scale: psychometric characteristics, reliability and validity in the israeli population covid-19: rights experts highlight lgbti discrimination, antisemitism stressors of nurses in psychiatric hospitals during the covid-19 outbreak psychological status of surgical staff during the covid-19 outbreak beyond homonegativity: understanding hong kong people's attitudes about social acceptance of gay/lesbian people, sexual orientation discrimination protection, and same-sex marriage psychological status of parents of hospitalized children during the covid-19 epidemic in china unprecedented disruption of lives and work: health, distress and life satisfaction of working adults in china one month into the covid-19 outbreak funding, conceptualization, methodology, formal analysis, investigation , resources, writing funding, conceptualization, methodology, formal analysis, investigation , resources, writing methodology, formal analysis, investigation, writing -review and editing formatted: normal formatted: font: 11 pt formatted: normal key: cord-327976-pwe95zoi authors: singh, dr shweta; roy, assistant professor.miss deblina; sinha, clinical psychology trainee miss krittika; parveen, clinical psychology trainee miss sheeba; sharma, clinical psychology trainee. ginni; joshi, clinical psychology trainee. gunjan title: impact of covid-19 and lockdown on mental health of children and adolescents: a narrative review with recommendations. date: 2020-08-24 journal: psychiatry res doi: 10.1016/j.psychres.2020.113429 sha: doc_id: 327976 cord_uid: pwe95zoi background: covid-19 pandemic and lockdown has brought about a sense of fear and anxiety around the globe. this phenomenon has led to short term as well as long term psychosocial and mental health implications for children and adolescents. the quality and magnitude of impact on minors is determined by many vulnerability factors like developmental age, educational status, pre-existing mental health condition, being economically underprivileged or being quarantined due to infection or fear of infection. aims: this paper is aimed at narratively reviewing various articles related to mental-health aspects of children and adolescents impacted by covid-19 pandemic and enforcement of nationwide or regional lockdowns to prevent further spread of infection. methodology: we conducted a review and collected articles and advisories on mental health aspects of children and adolescents during the covid-19 pandemic. we selected articles and thematically organized them. we put up their major findings under the thematic areas of impact on young children, school and college going students, children and adolescents with mental health challenges, economically underprivileged children, impact due to quarantine and separation from parents and the advisories of international organizations. we have also provided recommendations to the above. conclusion: there is a pressing need for planning longitudinal and developmental studies, and implementing evidence based elaborative plan of action to cater to the psycho social and mental health needs of the vulnerable children and adolescents during pandemic as well as post pandemic. there is a need to ameliorate children and adolescents’ access to mental health support services geared towards providing measures for developing healthy coping mechanisms during the current crisis. for this innovative child and adolescent mental health policies policies with direct and digital collaborative networks of psychiatrists, psychologists, paediatricians, and community volunteers are deemed necessary. this paper is aimed at reviewing articles related to mental-health aspects of children and adolescents impacted by covid-19 pandemic and lockdowns. there is a need to carry out longitudinal and developmental studies and plan strategies to enhance children's and adolescent's access to mental health services during and after the current crisis. for this direct and digital collaborative network of psychiatrists, psychologists, pediatricians, and community volunteers are of vital importance. background: covid-19 pandemic and lockdown has brought about a sense of fear and anxiety around the globe. this phenomenon has led to short term as well as long term psychosocial and mental health implications for children and adolescents. the quality and magnitude of impact on minors is determined by many vulnerability factors like developmental age, educational status, pre-existing mental health condition, being economically underprivileged or being quarantined due to infection or fear of infection. aims: this paper is aimed at narratively reviewing various articles related to mental-health aspects of children and adolescents impacted by covid-19 pandemic and enforcement of nationwide or regional lockdowns to prevent further spread of infection. methodology: we conducted a review and collected articles and advisories on mental health aspects of children and adolescents during the covid-19 pandemic. we selected articles and thematically organized them. we put up their major findings under the thematic areas of impact on young children, school and college going students, children and adolescents with mental health challenges, economically underprivileged children, impact due to quarantine and separation from parents and the advisories of international organizations. we have also provided recommendations to the above. conclusion: there is a pressing need for planning longitudinal and developmental studies, and implementing evidence based elaborative plan of action to cater to the psycho social and mental health needs of the vulnerable children and adolescents during pandemic as well as post pandemic. there is a need to ameliorate children and adolescents' access to mental health support services geared towards providing measures for developing healthy coping mechanisms during the current crisis. for this innovative child and adolescent mental health policies policies with direct and digital collaborative networks of psychiatrists, psychologists, paediatricians, and community volunteers are deemed necessary. key words: covid-19; lockdown; mental health; children; adolescents there are more than 2.2 billion children in the world who constitute approximately 28% of the world's population. those aged between 10 to 19 years make up 16 % of the world's population (unicef, 2019) . covid-19 has impacted the lives of people around the world including children and adolescents in an unprecedented manner. throughout the world, an essential modus of prevention from covid-19 infection has been isolation and social distancing strategies to protect from the risk of infection (shen et al., 2020) . on these grounds, since january, 2020, various countries started implementing regional and national containment measures or lockdowns. in this backdrop one of the principal measures taken during lockdown has been closure of schools, educational institutes and activity areas. these inexorable circumstances which are beyond normal experience, lead to stress, anxiety and a feeling of helplessness in all. it has been indicated that compared to adults, this pandemic may continue to have increased long term adverse consequences on children and adolescents (shen et al., 2020) . the nature and extent of impact on this age group depend on many vulnerability factors such as the developmental age, current educational status, having special needs, pre-existing mental health condition, being economically under privileged and child/ parent being quarantined due to infection or fear of infection. the following sections discuss about findings of studies on mental-health aspects of children and adolescents impacted by covid-19 pandemic and lockdowns being implemented at national or regional levels to prevent further spread of infection. we searched the electronic data bases of medline through pubmed, cochrane library, science-direct and google scholar databases, from january,2020 till june,2020. we carried out the search with the following methods like, mesh or free text terms and boolean were done by five independent reviewers. a manual search was also conducted of the references of the related articles to gather information about the relevant studies. initial pubmed search with the term with " covid-19 in children" showed only 12 results. among these, only four articles were related to "psychological effects of covid in children". therefore in order to make the review more comprehensive and informative, we also included studies that reported the effect on older children and impact of covid1-19 on their lives. this was done keeping in mind the varied terminologies used to describe the phenomenon of 'children and covid-19". after using the above strategy, our search showed 112 results. only articles in english language peer reviewed journals were included. grey literature such as conference proceedings were not included due to possibility of insufficient information. we included case studies and review articles and advisories by the who (world health organization), apa (american psychiatric association) and nhs ( national health services) and government of india ministry of health. based on these inclusion criteria we included 22 articles. three independent authors participated in study selection and all authors reached a consensus on the studies to be included. being a narrative review, we did not attempt computation of effect sizes or do a risk of bias assessment for included papers. the studies included were categorized under eight headings divided in various thematic sections and discussed with studies and reports found. the data is qualitatively analysed and reported in the paper. a summary of the papers included in this narrative review is presented in table 1. [ table 1 is uploaded seperately] impact on young children: stress starts showing its adverse effect on a child even before he or she is born. during stress, parents particularly pregnant mothers are in a psychologically vulnerable state to experience anxiety and depression which is biologically linked to the wellbeing of the foetus (biaggi et a 2016; kinsella and monk, 2009 ). in young children and adolescents the pandemic and lockdown have a greater impact on emotional and social development compared to that in the grown-ups. in one of the preliminary studies during the on-going pandemic, it was found younger children (3-6years old) were more likely to manifest symptoms of clinginess and the fear of family members being infected than older children (6-18 years old). whereas, the older children were more likely to experience inattention and were persistently inquiring regarding covid-19. although, severe psychological conditions of increased irritability, inattention and clinging behaviour were revealed by all children irrespective of their age groups (viner et al., 2020a) . based on the questionnaires completed by the parents, findings reveal that children felt uncertain, fearful and isolated during current times. it was also shown that children experienced disturbed sleep, nightmares, poor appetite, agitation, inattention and separation related anxiety (jiao et al., 2020) . globally, the pre-lockdown learning of children and adolescents predominantly involved one-to-one interaction with their mentors and peer groups. unfortunately, the nationwide closures of schools and colleges have negatively impacted over 91% of the world's student population (lee, 2020). the home confinement of children and adolescents is associated with uncertainty and anxiety which is attributable to disruption in their education, physical activities and opportunities for socialization (jiao et al., 2020) . absence of structured setting of the school for a long duration result in disruption in routine, boredom and lack of innovative ideas for engaging in various academic and extracurricular activities. some children have expressed lower levels of affect for not being able to play outdoors, not meeting friends and not engaging in the in-person school activities (lee, 2020; liu et al., 2020; zhai & du, 2020) . these children have become more clingy, attention seeking and more dependent on their parents due to the long term shift in their routine. it is presumed that children might resist going to school after the lockdown gets over and may face difficulty in establishing rapport with their mentors after the schools reopen. consequently, the constraint of movement imposed on them can have a long term negative effect on their overall psychological wellbeing (lee, 2020). a study found that older adolescents and youth are anxious regarding cancellation of examinations, exchange programs and academic events (lee, 2020) . current studies related to covid-19 demonstrate that school shut downs in isolation prevent about 2-4% additional deaths which is quite less if compared to usage of other measures of social distancing. moreover, they suggest to the policy makers that other less disrupting social distancing strategies should be followed by schools if social distancing is recommended for a long duration (lee, 2020; sahu, 2020; viner et al., 2020a) . however, in current circumstances, it is controversial whether complete closure of school and colleges is warranted for a prolonged period. it has been reported that panic buying in times of distress indicate an instinctual survival behaviour (arafat et al., 2020) . in present pandemic era there has been a rise in the hoarding behaviour among the teenagers (oosterhoff et al., 2020a) . it is also found that among youth social distancing is viewed primarily as a social responsibility and it is followed more sincerely if motivated by prosocial reasons to prevent others from getting sick (oosterhoff et al., 2020a) . further, due to prolonged confinement at home children's increased use of internet and social media predisposes them to use internet compulsively, access objectionable content and also increases their vulnerability for getting bullied or abused (cooper, 2020; unicef, 2020b) . worst of all, during lockdown when schools, when legal and preventative services do not functioning fully, children are rarely in a position to report violence, abuse and harm if they themselves have abusive homes. there are about 1 in every 6 children within the age group of 2-8 years who have some or the other neurodevelopmental, behavioural or emotional difficulty (cdc, 2019). these children with special needs [autism, attention deficit hyperactivity disorder, cerebral palsy, learning disability, developmental delays and other behavioural and emotional difficulties] encounter challenges during the current pandemic and lockdown (cdc, 2019). they have intolerance for uncertainty and there is an aggravation in the symptoms due to the enforced restrictions and unfriendly environment which does not correspond with their regular routine. also, they face difficulties in following instructions, understanding the complexity of the pandemic situation and doing their own work independently. with the closure of special schools and day care centres these children lack access to resource material, peer group interactions and opportunities of learning and developing important social and behavioural skills in due time may lead to regression to the past behavior as they lose anchor in life, as a result of this their symptoms could relapse (lee, 2020). these conditions also trigger outburst of temper tantrums, and conflict between parents and adolescents. although prior to the pandemic, these children had been facing difficulties even while attending special schools, but in due course they had learnt to develop a schedule to adhere to for most of the time of the day (apa, 2020; cortese et al., 2020; unicef, 2020a). to cater to these challenges, it is difficult for parents to handle the challenged children and adolescents on their own, as they lack professional expertise and they mostly relied on schools and therapists to help them out (dalton et al., 2020). since every disorder is different, every child has different needs to be met. the children with autism find it very difficult to adapt to the changing environment. they become agitated and exasperated when anything is rearranged or shifted from its existing setup. they might show an increase in their behavioral problems and acts of self-harm. it is a huge challenge for parents to handle autistic children due to lockdown. the suspension of speech therapy and occupational therapy sessions could have a negative impact on their skill development and the achievement of the next milestone, as it is difficult for them to learn through online sessions (unicef, 2020a). the children with attention deficit hyperactivity disorder (adhd), struggle to make meaning of what is going around them from the cues they get from their caregivers. it is difficult for them to remain confined to a place and not to touch things, which might infect them. due to being confined to one place the chances of their hyperactivity increases along with heightened impulses and it becomes difficult for the caregivers to engage these children in meaningful activities (cortese et al., 2020). obsessive compulsive disorder (ocd) among the children and adolescents is estimated to be of 0.25%-4% among children and adolescents (cdc, 2019). children with ocd are suspected to be one of the most affected ones by this pandemic. due to obsessions and compulsions related to contamination, hoarding, and somatic preoccupation, they are expected to experience heightened distress. cleanliness is one key protective measure against the spread of covid-19. according to united nations' policy guidelines to fight the infection one has to be careful about washing their hands six times a day, and whenever they touch anything (apa, 2020; united nations, 2020). the lockdown, which has made the healthy population distressed about possessing enough food and prevention related resources like masks and sanitizers, has made it worse for people with hoarding disorder (apa, 2020; mukherjee et al., 2020) social inequality has been associated with the risk of developing mental health challenges. the pandemic and lockdown world has experienced global economic turn-down which has directly worsened the pre-existing social inequality. in developing countries, with the in order to cover up the loss of education during lockdown, many schools have offered distance learning or online courses to students. however, this opportunity is not available to underprivileged children as a result of which they face a lack of stimulation and have no access to online resource material to study. a study pointed out that in underprivileged families, in comparison to boys, girls have decreased access to gadgets, this may diminish their involvement in digital platforms of education (mcquillan & neill, 2009 ). due to this gender inequality, increasing number of girls are prone to bear the consequences of school dropouts once the lockdown is lifted (cooper, 2020; pti, 2020). covid with the objective of universal prevention and mental health promotion, the international it is imperative to plan strategies to enhance children and adolescent's access to mental health services during and after the current crisis. for this direct and digital collaborative network of various stakeholders is required. recommendations for ensuring mental well-being of children and adolescents during the covid-19 pandemic and lockdown and the role of parents, teachers, pediatricians, community volunteers, the health system and policy makers are being discussed. in addition a brief summary of the roles is given in table 2 . [ table 2 is uploaded seperately] in the times of paramount stress and uncertainty, a secure family environment which the parents can provide is a strong protective factor (schofield et al., 2013) . there is evidence to 5. efforts should be made so that a consistent routine is followed by the child, with enough opportunities to play, read, rest and engage in physical activity. it is recommended that family plays board games and engages in indoor sports activities with the child to avoid longer durations of video games. parents should ensure that particularly the bedtime of a child is consistent. it is possible that before the bed time children may need some more time and attention. 6. focus should be on the 'good behaviour' more than 'bad behaviour' of a child. parents must tell more about options regarding what to do rather than what not to do. provide more praise and social reinforcements to children compared to material reinforcements. 7. it is quite possible that parents observe some amount of change in the behavior in children during the times of a pandemic. if the behavior problems are minor and not harmful for children and others, parents should consider ignoring and stop paying attention to them, this may lead to decrease in the recurrence in behavior and would also help in giving space to each other. apart from areas discussed above, certain areas which need especial focus in the phase of adolescence, are being described below: 3. this is an opportunity for older children to learn responsibility, accountability, involvement, and collaboration. by taking some responsibilities at home on an everyday basis, for instance maintenance of their belongings and utility items. they can learn some of the skills including cooking, managing money matters, learning first aid, organizing their room, contributing to managing chores like laundry, cleaning and cooking. 4. excessive internet use e.g. internet surfing related to covid-19 should be avoided as it results in anxiety. similarly, excessive and irresponsible use of social media or internet gaming should be cautioned against. negotiations with adolescents to limit their time and internet-based activities are recommended. more non-gadget related in door activities and games are to be encouraged. 5. in such conditions taking up creative pursuits like art, music, dance and others can help to manage mental health and well-being for everyone. inculcating self-driven reading by making them select books of their choice and discussing about them helps in adolescent development. 6. adolescence is a phase of enthusiasm and risk-taking, hence some may feel invincible and try not to follow guidelines related to distancing and personal hygiene. this has to be addressed with adolescents assertively. 7. it is crucial to value the peer support system of the adolescents. parents should encourage adolescents who are introverts to keep in touch with their peers and communicate with them about their feelings and common problems they face. this may also lead a way for appropriate problem-solving. 8. it is advised to parents to take care of their own mental health needs and try to cope with stress adaptively. in the present times when most schools and colleges are organizing online academic activities, teachers are in regular touch with students, and therefore are in a position to play a critical role in the promotion of psychological well being among youngsters. their role during covid-19 pandemic and lockdown are as follows: 1. teachers can devote some time related to educating about covid-19 and preventive health behavior by using the guidelines of the international organizations, according to the maturity level of the students. they can explain to the students about the need to act with responsibility during the current pandemic. they can model and enact through their behavior the preventive measures. 3. they can conduct creative online academic and non-academic sessions by making their classes more interactive, engaging students in the form of quizzes, puzzles, small competitions, and giving more creative home assignments to break the monotony of the online classes. standard educational material can be used. for instance, unesco has offered many online educational sources (unesco, 2020) they can discuss what is wellbeing and how it is important for students. they can assist in teaching simple exercises, including deep breathing, muscle relaxation, distraction, and positive self -talk. virtual workshops can be conducted in which 'life skills' related to coping in stress can be in focus by using more practical examples. 5. teachers can make children understand the importance of prosocial behavior and the importance of human virtues like empathy and patience among others. this can help them to understand their role in the society and understand how social distancing is not equivalent to emotional distancing. 6. the teachers need to interact with parents online or through phone regarding feedback about students and their mental health. because of the digital divide they can call parents, make their contact available to parents and devote a time slot when they can be available to parents to communicate. 7. they can serve as a doorway for identification and referral to specialty mental health providers. they have a role act as a catalyst between the parent based on their interaction with students and findings of screening tools. if they observe any problem in the child, they can talk to parents and refer children and adolescents to mental health professionals. 8. with the support of school authorities, teachers need to make arrangements to ensure that the reading material related academics and life skills is made available to the underprivileged children who do not have access to the internet. if possible arrangements can be made for them to use internet. during a child's formative years when their personalities are shaped, parents are in regular touch with pediatricians, as parents reach out to their local pediatricians whenever they encounter health/ behavioral complaints associated with their children. parents expect answers from them as they trust them. hence a pediatrician's role is paramount in promoting ptsd, depression, substance abuse in adolescents should also be addressed on similar lines. there is a requirement for creative solutions, often on a case-by-case basis. 9. psychiatrists need to carefully weigh the risks and benefits of psychotropic medications for children and adolescents e.g. anti-depressants, anxiolytics, anticonvulsants, etc., and if possible, arranging medicines for those who cannot arrange. 10. there is a need for mental health care workers carry out longitudinal and developmental studies on short term and long term mental health impact of the covid 19 pandemic and lock down on children and adolescents. it has been recognized by the world that the traditional pre-covid-19 models and policies for children and adolescents' mental health are no longer applicable during covid 19 era. hence, the need is felt for the transformation of policies that can take into account not only lock down duration but also times following the lockdown. the following recommendations may be useful for guiding the functioning of the health system and policy making related to mental health care of children and adolescents : 1. the focus of the health care system should be prevention, promotion, and treatment according to the public mental health system to meet population-mental health needs of the general population at large. no single umbrella policy would be able to take into account various mental health aspects of children and adolescents dwelling in different environments. hence the health system and policies should be based on contextual parameters that are different for each country or region depending on the degree of infection and the phase of infection they are in. 3. since there is a dearth of mental health care workers in most developing countries. there is a need for inclusive approaches in which health care workers e.g. pediatricians, general physicians, schools, non-governmental organizations sectors are involved. moreover, brief basic mental health care training for these arms should be planned. 4. separate rules for the rural, suburban, and concrete domiciles in growing countries spotting the variance among college districts, which includes city, suburban, and rural districts. the studies included in the review were collected after setting criteria to have a comprehensive view of the global vision in managing the crisis of children in the covid-19 pandemic. the majority of the studies included in the review were based on online selfreports (bhat et al., 2020; jiao et al., 2020; oosterhoff et al., 2020b) . the adults and older children were the respondents of the study (lee, 2020; liu et al., 2020; viner et al., 2020b; wang et al., 2020 (wade et al., 2020) . the review articles for this review have been selected during the time of global lockdown, where the issues and challenges were new and the global crisis was at peak times. in our review, we were unable to track the measures of management targeted towards the children. the strategies reported in the studies were isolated to geopolitical conditions. the recommendations provided in this review can be modified to suit the needs of the places according to their local resources and geopolitical scenarios. due to strict selection criteria and the short period of data collection and the only use of electronic databases for our research, there is a possibility of missing studies relevant to the care of children and adolescents. although the rate of covid-19 infection among young children and adolescents is low the children who receive training, therapy, and other treatments are at high risk of being derailed from therapy and special educations. economically underprivileged children are particularly prone to exploitation and abuse. children quarantined are at high risk for developing higher risk for mental health-related challenges. there is a need to ameliorate children and adolescent's access to mental health services by using both face to face as well as digital platforms. for this collaborative network of parents, psychiatrists, psychologists, pediatricians, community volunteers, and ngos are required. there is a need for 'tele mental health compatibility' and be accessible to the public at large. this would be crucial to prevent during and post-pandemic mental challenges in the most vulnerable and underprivileged section of the society. the focal point of the health care system and policymaking should be prevention, promotion, and interventions corresponding to the public mental health system to meet the mental health needs of the population at large by taking the regional contextual parameters into account. disclosure of prior presentation of study data: this paper has not been submitted in full or part in any conference and is not being considered for publication elsewhere. creating material for community volunteers and ngos for identifying high risk children e.g. underprivileged children, children of migrants, provide psychological first aid, coordinating with care givers and mental health care professionals. quarantined parents/children parents if child is separated to keeping contact as much as possible, being supportive and reassuring coordinating with care givers, referring to mental health care professionals foster care givers being supportive, reassuring and educating constructing and administring online questionnaires in order to detect psychological distress and other symptoms for children if they or their parents are quarantined, providing extra support to them and developing ad hoc supportive interventions. impacts of covid-19 on vulnerable children in temporary accommodation in the uk. the lancet public health closure of universities due to coronavirus disease 2019 (covid-19): impact on education and mental health of students and academic staff professional foster carer and committed parent: role conflict and role enrichment at the interface between work and family in long-term foster care diagnosis, treatment, and prevention of 2019 novel coronavirus infection in children: experts' consensus statement children's mental health in times of economic recession: replication and extension of the family economic stress model in finland global population of children 2100 children with autism and covid-19 policy brief: the impact of covid-19 on children school closure and management practices during coronavirus outbreaks including covid-19: a rapid systematic review. the lancet child & adolescent health school closure and management practices during coronavirus outbreaks including covid-19: a rapid systematic review. the lancet child & adolescent health why we need longitudinal mental health research with children and youth during (and after) the covid-19 pandemic detection of sars-cov-2 in different types of clinical specimens healthy parenting who | covid-19: resources for adolescents and youth world health organization mental health care for international chinese students affected by the covid-19 outbreak the authors whose names are listed below certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants, participation in spakers' bureaus arrangements, consultancies, memberships, stock ownerships, or other equity interest, or expert testimony and patent licencing arangements) or non financial interests such as ( personal or professional relationships, affiliations, knowledge or beliefs)in the subject matter or materials discussed in this manuscript. all the authors confirm that, all of them has contributed in the conception of design; analysis, interpretation of data; drafting the article; critically revisiting the article for important intellectual inputs; and approval of the final version. this paper has not been submitted elsewhere or is under review at another journal or publishing venue. the authors have no affiliation with any organization, with a direct or indirect financial interest in the subject matter discussed in the manuscript. authorities to be more transparent in their negotiations and to allow candidates sufficient notice to prepare emotionally as well. students to be timely provided counselling. 