key: cord-318737-b32tk5ze
authors: Stickley, Andrew; Matsubayashi, Tetsuya; Sueki, Hajime; Ueda, Michiko
title: COVID-19 preventive behaviours among people with anxiety and depressive symptoms: Findings from Japan
date: 2020-10-10
journal: Public Health
DOI: 10.1016/j.puhe.2020.09.017
sha: 
doc_id: 318737
cord_uid: b32tk5ze

Objectives To examine COVID-19 preventive behaviours among individuals with mental health problems. Study design A pooled cross-sectional study. Methods Online survey data were analyzed from 2000 Japanese adults collected in April and May, 2020. Information was obtained on 13 COVID-19 preventive behaviours, and anxiety and depressive symptoms using the Generalized Anxiety Disorder Scale (GAD-7) and the Patient Health Questionnaire (PHQ-9), respectively. Linear regression analysis was used to examine the associations. Results In models adjusted for demographic and socioeconomic factors, anxiety (Coefficient: -0.77, 95% confidence interval [CI]: -1.30,-0.24) and depressive symptoms (Coefficient: -0.82, 95%CI: -1.34,-0.30) were both associated with significantly lower engagement in COVID-19 preventive behaviours. Conclusion Our results highlight the importance of facilitating the performance of preventive behaviours in individuals with mental health problems to prevent the spread of COVID-19 in this population.

As yet, there has been little research on the association between common mental disorders (CMDs) and infectious disease, and it is thus uncertain how the presence of pre-existing CMDs such as anxiety and depression might be linked to health behaviours during the ongoing COVID-19 pandemic. A recent editorial has suggested for example, that differing levels of health anxiety might result in either a maladaptive engagement in (e.g. excessive hand washing [high anxiety]) or a disregard for (e.g. no hand washing [low anxiety]) preventive behaviours. 1 In addition, other authors have previously hypothesized that characteristics associated with CMDs such as depression, including lower levels of energy, a decreased focus, and greater hopelessness might also be important for (non-)engagement in necessary health behaviours. 2 The few studies that have examined how CMDs are linked to infectious disease preventive behaviours have produced mixed results. An earlier study from Hong Kong found that compared to those with low anxiety, individuals with high, and especially moderate levels of anxiety had significantly higher odds for adopting ≥ 5 precautionary measures against severe acute respiratory syndrome (SARS). 3 Support for the notion that CMDs might be associated with increased engagement in preventive behaviours also comes from another study from Hong Kong, which recently found that people with symptoms of anxiety were more likely to adopt social distancing measures in response to the threat of COVID-19. 4 In contrast, other research from China found that anxiety was not related to any differences in the adoption of preventive measures, while people with depression took fewer preventive measures in response to the COVID-19 pandemic. 5 The current study will examine the effects of anxiety and depressive symptoms on COVID-19 preventive behaviours in a sample of the Japanese general population. A focus on Japan may be particularly instructive. Although the effects of COVID-19 have not been as severe in Japan as in many other countries -at least in terms of the number of deaths -coronavirus cases began to increase quickly from early-mid July following the ending of a nationwide state of emergency in late May. This increase may be linked to several factors including the use/non-use of preventive measures. Specifically, a recent study has reported that although the vast majority of Japanese adults have adopted preventive measures, around 20% of the working-age population (age 20-64) is reluctant to do so. 6 However, that study did not specifically focus on the possible effects of CMDs in the non-use of preventive behaviours. Linear and logistic regression analyses were performed to examine the association between anxiety and depressive symptoms and preventive behaviours. In the first analysis a combined preventive behaviour score variable was created by summing the responses for each preventive behaviour and linear regression analysis was used to examine the associations. In the second analysis the association between anxiety and depressive symptoms and each of the individual preventive behaviours was examined using binomial logistic regression. All analyses were adjusted for the above-listed covariates. The standard errors were heteroskedasticity-robust, and clustered by prefecture. The analysis was conducted using STATA/MP (version 16, Stata Corporation, College Station, TX). The results are presented as coefficients (Coef.) and odds ratios (OR) with 95% confidence intervals (CI). The level of statistical significance was set at p < 0.05 (two-tailed).

The frequency of anxiety and depressive symptoms was 10.9% and 17.3%, respectively.

Both anxiety (Coef: -0.77, 95%CI: -1.30,-0.24) and depression (Coef: -0.82, 95%CI: -1.34,-0.30) were associated with significantly reduced engagement in all of the preventive behaviours combined (Table 1) . For anxiety, in the logistic regression analyses ORs were negative for 11 of the 13 preventive behaviours (Appendix A). Individuals with symptoms of anxiety were significantly less likely to engage in six of the preventive behaviours. Specifically, they had a 40-49% reduction in the odds for washing hands, wearing a mask and avoiding crowds, and a 26-38% reduction in the odds for using a tissue/sleeve when coughing/sneezing, avoid touching face and cancel going out. Depressive symptoms were also associated with significantly reduced odds for the same six preventive behaviours. In addition, they were also associated with a 27% reduction in the odds for avoiding engaging in gatherings (OR: 0.73, 95%CI: 0.58-0.90).

Although a study from China reported that neither state nor trait anxiety was associated with COVID-19 preventive behaviours, 5 other recent studies have all linked anxiety with an increased likelihood of engaging in preventive behaviours. 4, 9, 10 This conflicts with our finding that anxiety symptoms were associated with reduced preventive behaviour. It is uncertain what underlies this difference, but underlines the need for future studies to collect information on the specific causes of anxiety, especially as it has been suggested that high levels of health anxiety might be linked to engaging in excessive preventive behaviour. 1 Regarding depression, our findings accord with those from the above-mentioned Chinese study, which showed that depressive symptoms may inhibit preventive behaviours in response to the COVID-19 pandemic. 5 It is possible that various mechanisms might underlie the association between CMDs and reduced preventive behaviour in Japanese adults. For example, it can be speculated that symptoms that are characteristic of these disorders such as fatigue and reduced concentration might be important in this regard.

This study has some limitations. The use of cross-sectional data meant that we were not able to establish causality or the direction of the observed associations. In addition, we also lacked information on prior psychiatric diagnoses of the respondents. It is possible therefore, that poorer mental health might have been a psychological response to the threat of COVID-19 or the rigours of quarantine. Keeping this in mind, the results of this study indicate that people with mental health problems may be at increased risk for COVID-19 infection given their lower engagement in a number of preventive behaviours. This highlights the importance of educating individuals with poorer mental health about the dangers of COVID-19 and how to protect J o u r n a l P r e -p r o o f themselves against the virus. In addition, our findings also suggest that further research on the effects of COVID-19 among individuals with mental health problems is now urgently warranted.

J o u r n a l P r e -p r o o f Table 1 Association between anxiety and depressive symptoms and all COVID-19 preventive behaviours combined among Japanese adults † 

How health anxiety influences responses to viral outbreaks like COVID-19: what all decision-makers, health authorities, and health care professionals need to know

Depression and medication adherence in outpatients with coronary heart disease: findings from the Heart and Soul Study

The impact of community psychological responses on outbreak control for severe acute respiratory syndrome in Hong Kong

Community responses during early phase of COVID-19 epidemic

Psychological status and behavior changes of the public during the COVID-19 epidemic in China

Japanese citizens' behavioral changes and preparedness against COVID-19: an online survey during the early phase of the pandemic

Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire

A brief measure for assessing generalized anxiety disorder: the GAD-7

Public perceptions and preventive behaviours during the early phase of the COVID-19 pandemic: a comparative study between

Assessment of community psycho-behavioral responses during the outbreak of novel coronavirus (2019-nCoV): a cross sectional study

Anxiety and depressive symptoms were the exposures; COVID-19 preventive behaviours were the outcomes Coef: coefficient; CI: confidence interval Both analyses were adjusted for age (ref. young), sex (ref. female), education (ref. less than college), income (ref. high income), household financial situation (ref. better/same as in previous year), employment (ref. unemployed not in the labour force)

This study was approved by the Ethics Committee of Waseda University (approval case number: 2020-050) and Osaka School of International Public Policy, Osaka University. The survey participants were informed of the purpose of the study prior to their participation and had the option to quit the survey at any time. The respondents provided explicit consent that the information they provided could be used for the purpose of this study. The data are completely anonymous.

Number 20H01584. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The authors declare that they have no conflicting interests.

MU and TM were responsible for data acquisition. AS wrote the main text. MU analyzed the data and contributed to the writing of the text. TM, HS reviewed and revised the manuscript.
