key: cord-323789-mb3qdfj5 authors: preis, heidi; mahaffey, brittain; heiselman, cassandra; lobel, marci title: pandemic-related pregnancy stress and anxiety among women pregnant during the covid-19 pandemic date: 2020-06-15 journal: am j obstet gynecol mfm doi: 10.1016/j.ajogmf.2020.100155 sha: doc_id: 323789 cord_uid: mb3qdfj5 nan prenatal maternal stress and anxiety, whether at times of disaster or not, are well-7 established risk factors for preterm birth, low birth weight, infant health problems, and may have 8 long lasting effects on offspring. 1, 2 approximately 21%-25% of women experience prenatal 9 anxiety symptoms (e.g., excessive worry, nervousness, agitation). policies to decrease the spread 10 of the novel corona virus disease , and anxiety (generalized anxiety disorder-7 [gad-7] with clinical cut-offs: 27 0-4 no/minimal, 5-9 mild, 10-14 moderate, 15-21 severe). analysis on a random half of the sample confirmed its three constituent factors: preparedness 31 stress (7 items; e.g., "i am worried i will not be able to have someone with me during the 32 delivery"), perinatal infection stress (5 items; e.g., "i am worried that my baby could get step 1 step 2 step 3 disasters and perinatal health: a systematic review key: cord-355015-e681jmix authors: cici, remziye; yilmazel, gülay title: determination of anxiety levels and perspectives on the nursing profession among candidate nurses with relation to the covid‐19 pandemic date: 2020-08-10 journal: perspect psychiatr care doi: 10.1111/ppc.12601 sha: doc_id: 355015 cord_uid: e681jmix purpose: this study aimed to determine the anxiety level of candidate nurses and capture their perspective on the nursing profession in light of the coronavirus disease 2019 (covid‐19) pandemic. design and methods: this descriptive study consisted of 322 nursing students in turkey after the pandemic announcement of the world health organization. a web‐based survey was used and anxiety levels was determined via state anxiety scale and beck anxiety inventory. findings: positive perspectives (63.4%) on the nursing profession before the pandemic decreased to 50.6%, whereas the negative (26.7%), and the undecided (9.9%) perspectives increased to 32.3% and 17.1%, of the total respectively. a significant increase was found in the anxiety scores with negative perspectives combined with an unwillingness to practice their profession in the future (p < .05). practice implications: pregraduate training should be provided to candidate nurses about pandemic nursing and professional difficulties they may possibly encounter in infection epidemics. questions in the beck anxiety inventory. the participants were called by phone and were informed about the purpose of the study. it was questioned whether they could participate in this study through online survey. after the verbal consents of the participants were obtained, written informed consents were sent to them by e-mail. data were collected when participants filled out online questionnaire. a form includes the sociodemographic characteristics (age, gender, classroom level) and the perspective of the candidate on the profession before and during the pandemic. the candidate's perspective on the profession was captured with help of two survey questions: first, "what was your perspective on the nursing profession before and during the covid-19 pandemic?", to which the answer choices were "positive," "negative," and "undecided." the second question asked, "are you willing to practice your profession in the future?" and the answer choices were "yes" and "no." self-assessments of the influence of the pandemic on mental health and the fear with regard to the risk of contagion were also captured with questions with the answers "yes and no." the state anxiety scale was developed by spielberger in 1970, and the turkish version and its corresponding validity-reliability study was adapted by oner and le compte in 1983. 18, 19 in the turkish version of the scale, consistency and reliability were found to be between 0.94 and 0.96. the scale consists of 20 items and answers range from 1 to 4 (1: never, 2: some, 3: very, 4: completely). the total score value obtained from the scale is between 20 and 80. high scores indicate high anxiety levels. 18, 19 although the scale does not have a cutoff point, it is generally accepted that the cutoff point is 39 to 40 points. 20 in this study, cronbach's α coefficient of the scale was determined to be .72. are evaluated as "0" (none), "1" (mild), "2" (moderately), and "3" (severely). the total score obtained from the scale varies between 0 and 63, and high scores are representative of high anxiety levels. 21, 22 in this study, cronbach's α coefficient of the scale was determined to be 0.92. this study was planned according to the helsinki principles, and ethical approval was obtained from the hitit university non-interventional research ethic committee. data were analyzed using the spss 17 program with percentages, mean, independent t test, and a one-way analysis of variance (posthoc tukey). in the analysis, p < .05 value considered statistically significant. of the study group, 72% were between 18 and 21 age groups with mean age of 20.8 years. a total of 76.4% of those who were surveyed were female, and 31.1% were training in the second grade. table 1 shows the distribution of anxiety scores. as seen in table 1 , students' beck anxiety scores ranged from 0 to 63 with an average of 15.2 ± 8.4 points. it was determined that 50.9% of the participants scored 16 and above. it was determined that the state anxiety level of the participants was at the full limit (40.3 ± 4.9) and the state anxiety score was 40 and above in 51.9% of the cases. the changes in students' perspectives on the nursing profession due to the covid-19 pandemic are shown in figure 1 . it was observed that the positive views of the participants toward the nursing profession, stood at 63.4% before the pandemic, but decreased to 50.6% during the pandemic. on the other hand, negative and undecided views of the profession were held by 26.7% and 9.9% of those who were surveyed before the pandemic, and increased to 32.3% and 17.1%, respectively. in table 2 , the distribution of anxiety scores according to the perspectives on nursing profession is given. as seen in table 2 , while the anxiety scores did not differ significantly according to the perspectives on the nursing profession before the covid-19 pandemic (p > .05), a significant increase in anxiety scores was found in those with a negative perspective of the profession during the pandemic (p < .05). anxiety scores were found to be significantly higher for those with the unwillingness to practice the profession in the future (p < .05). the distribution of anxiety scores according to mental influence due to pandemic and fear of being infected with covid-19 is given in table 3 . anxiety scores were found to be significantly higher among those with mental influence and afraid of being infected (p < .05). in the present study, anxiety levels of candidate nurses were determined to be wide ranging due to the covid-19 pandemic. anxiety and state anxiety were found in more than half of the participants (table 1) . facing large-scale infectious disease threats may increase the psychological pressure on individuals. 23 epidemics may also trigger psychological problems among health workers who work in the front line. a recent community-based study in china reported that approximately one-third of the participants had moderate to severe anxiety and more than half of the participants had moderate to severe psychological effects, as a result of the pandemic. 24 whereas the psychological pressure caused by pandemics affects the general public, its effect on health care providers working in the frontline is markedly greater. experiences of healthcare professionals in the current covid-19 epidemic, underlined the psychological pressure on healthcare professionals who find themselves at the forefront of attempts to suppress the outbreak. 23, 25 in another study conducted in china, it was demonstrated that the incidence of anxiety and stress disorder was high among healthcare workers working in the frontline due to covid-19 and the incidence was comparatively higher among nurses than doctors. 16 rapid decision making for suspected cases, careful isolation of patients, determining the specific departments to work, and using the the perception of risk, and the confidence in professional skills among health workers were factors that facilitate the willingness to work. 26 when the participants' perspectives on the profession before and during the pandemic were compared, it was determined that there was a clear change in their perspectives on the negative and undecided responses toward the profession (figure 1 ). anxiety and state anxiety scores were found to be significantly higher among those with a negative perspective regarding their profession as a result of the pandemic and they were unwilling to practice their job in the future ( anxiety scores were quite high among those who were mentally affected due to pandemic and had a fear of being infected (table 3) . it is recommended to develop psychological support for health workers working in the frontlines and provide adequate interventions so as to assist them to endure the increased psychological pressure as a result of the pandemic. 25, 27 in light of past epidemic experiences, protective strategy should be planned for all healthcare professionals, especially nurses and candidate nurses. in summary, in our study, it was found that anxiety levels increased due to the covid-19 pandemic, and perspectives on the profession showed a negative trend due to the pandemic among candidate nurses. nursing is a life-saving profession and addresses reflecting every aspect of treatment and care in health services. global health threats such as pandemics may bring unprecedented demands on most nurses' knowledge, skill and moral resolve and anxiety management. pregraduate training should be provided to candidate nurses about pandemic nursing and professional difficulties they may encounter in infection epidemics. anxiety may decrease willingness and ability of candidate nurses to profession during a pandemic. to minimize these problems, education plans should be made to keep candidate nurses more active in community health services. in the pandemic phase, more studies should be planned to determine the mental health problems of the candidate nurses, and psychological counseling, guidance, and mental health services should be provided for those at risk. clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study mental health care for medical staff in china during the covid-19 outbreak asymptomatic and presymptomatic sars-cov-2 infections in residents of a long-term care skilled nursing facilityin morbidity and mortality weekly report summary ministry of health. 2020. covid-19 guide critical care crisis and some recommendations during the covid-19 epidemic in china. intensive care med covid-19 coronavirus pandemıc ministry of health. 2020. turkey coronavirus daily chart genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding coronavirus disease 2019 (covid-19): a guide for uk risk reduction in healthcare workers in the covid-19 outbreak special attention to nurses' protection during the covid-19 epidemic new coronavirus pneumonia (covid-19) joint investigation report turkish medical association. 2020. koronavirüs (covid-19 vicarious traumatization in the general public, members, and non-members of medical teams aiding in covid-19 control mental health survey of 230 medical staff in a tertiary infectious disease hospital for covid-19 nursing students' attitudes towards the nursing profession, nursing preferred with the relationship between: example of turkey state trait anxiety inventory handbook. istanbul: boğaziçi university publisher dordrecht: palo alto, consulting psychologists press anxiety level and difficult patients in prosthodontic clinic an inventory for measuring clinical anxiety: psychometric properties turkish version of the beck anxiety inventory: psychometric properties psychometric_properties/links/0912f50b89f36c598c000000.pdf covid-19 pandemic and its impact on mental health of healthcare professionals immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china psychological symptoms among frontline healthcare workers during covid-19 outbreak in wuhan healthcare workers' willingness to work during an influenza pandemic: a systematic review and meta-analysis. influenza other respir viruses a systematic, thematic review of social and occupational factors associated with psychological outcomes in healthcare employees during an infectious disease outbreak determination of anxiety levels and perspectives on the nursing profession among candidate nurses with relation to the covid-19 pandemic the authors declare that there are no conflict of interests. https://orcid.org/0000-0003-3977-492xgülay yilmazel http://orcid.org/0000-0002-2487-5464 key: cord-349836-m9b65l75 authors: malhotra, c.; chaudhry, i.; ozdemir, s.; teo, i.; finkelstein, e. a. title: anxiety and perceived risk during covid-19 outbreak date: 2020-07-24 journal: nan doi: 10.1101/2020.07.24.20161315 sha: doc_id: 349836 cord_uid: m9b65l75 the uncertainty around coronavirus disease-19 (covid-19) has triggered anxiety among public. we aimed to assess the variation in anxiety and risk perceptions of covid-19 among adults in singapore. we administered a web-survey to a panel of residents between 31 march and 14 april 2020. we assessed anxiety using general anxiety disorder (gad) scale and assessed participants risk perceptions regarding severity of the outbreak. of the 1,017 participants, 23% reported moderate to severe anxiety (gad score above 10). a high proportion reported perceived likelihood of icu admission (46%) and death (30%) upon getting covid-19. results from path analysis showed that younger participants, those with chronic conditions, those living with children and low perceived trust in government response to covid-19 had a significantly higher anxiety mediated by their perceived risk of dying upon getting covid-19. these results highlight the need for management of anxiety through adequate and effective risk communication for the general public. coronavirus disease-19 (covid-19) is a major public health crisis affecting several nations (dryhurst et al., 2020) . this unprecedented infectious disease outbreak resulted in stringent public health measures around the word to curtail its spread (qian et al., 2020) . in singapore, the first confirmed case of covid-19 was reported on january 23, 2020. by february 7, 2020, singapore's disease outbreak response system condition' (dorscon), a colour-coded framework for infectious disease outbreaks, turned orange, signifying that disease is severe and spreading easily. the uncertainty surrounding the covid-19 outbreak including the lack of information regarding the risk of acquiring covid-19, risk of developing complications and of dying due to it, and doubts about the adequacy of measures being taken to control the outbreak are likely to have created anxiety among people. the primary objective of this study is thus to assess prevalence of anxiety among adults in singapore during the covid-19 outbreak. we hypothesize that older adults and those with pre-existing chronic medical conditions-groups at greater risk of experiencing adverse outcomes due to covid-19 (mueller, mcnamara, & sinclair, 2020 ) -will experience greater anxiety. we also hypothesize that people living with children and with lower trust in the government's ability to control covid-19 outbreak will have greater anxiety (dryhurst et al., 2020; shevlin et al., 2020) . lastly, we hypothesize that these associations will be mediated by perceived risk of: i) getting covid-19 compared to a regular flu, ii) being admitted to intensive care unit (icu), and ii) death upon getting covid-19. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 24, 2020. . https://doi.org/10.1101/2020.07.24.20161315 doi: medrxiv preprint between 31 march and 14 april 2020, we administered a web survey to a panel of residents (>21 years) in singapore. we quota sampled based on age, ethnicity and gender to ensure representativeness. we assessed participants' anxiety using general anxiety disorder scale (gad-7) (spitzer, kroenke, williams, & löwe, 2006) , and described their age, living arrangement (i.e. whether living with children), and chronic medical conditions (self-reported from a list of 15 conditions). additionally, we assessed the extent of perceived trust in the government response to successfully contain covid-19. we also assessed participants' risk perceptions regarding the severity of covid-19. first, participants reported their chances of getting covid-19 compared to a regular flu. response options included "much lower than flu", "slightly lower than flu", "same as flu", "slightly higher than flu" or much higher than flu". additionally, respondents responded to the likelihood of icu admission and likelihood of death due to covid-19 on a 4-item likert scale ranging from "very unlikely" to "very likely". we used path analysis to test our hypotheses. we estimated standardized coefficients (with 95% ci) and assessed the model fit (chi-square and p-value, root mean square error of approximation (rmsea) (threshold <.05), and standardized root mean square residual (threshold <.05)). (pituch & stevens, 2015) we first assessed the significance of all hypothesized paths and then removed statistically insignificant (p ≥ 0.05) paths, and reassessed fit of the revised model. we used stata 16.1 for analyses. 1,017 participants completed the survey. over half the population were female (51%) and median (iqr) age was 40 years. our sample included majority of the respondents with a all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 24, 2020. . https://doi.org/10.1101/2020.07.24.20161315 doi: medrxiv preprint university degree (58%) and nearly one-third of the respondents (34%) had a pre-existing chronic condition. about a quarter (23%) of the respondents had symptoms of moderate and severe anxiety (gad score≥10). nearly a quarter (24%) felt that their chance of getting covid-19 was lower than getting flu. strikingly, a high proportion reported that they were likely to be admitted to an icu (46%) and to die upon getting covid-19 (30%) ( table 1) . results from our final model (figure 1 ) showed that those with -more chronic conditions, living with children and a lower perceived trust in government response to covid-19 had significantly higher anxiety, which was mediated by their perceived risk of dying upon getting covid-19. contrary to our hypothesis, younger adults experienced higher anxiety, and this associated was not mediated by perceived risk of dying upon getting covid-19. the model fit was good (chi-square (p-value) =4.043 (0.132); rmsea=0.03; smr=0.01). perceived risk of getting covid-19 compared to regular flu and risk of icu admission upon getting covid-19 did not mediate the association between any contextual factor and anxiety. a significant proportion of the participants reported moderate to severe anxiety (23%), much higher than what has been reported from population surveys before covid-19 outbreak, (lee, sagayadevan, vaingankar, chong, & subramaniam, 2015) and higher than those among health care professionals in singapore (tan et al., 2020) . the high proportion of people who overestimated their risk of being admitted to icu or dying if they get covid-19 is also notable. as trust in government response to contain covid-19 was high, we suggest that government agencies should carefully craft messages to communicate risk of adverse all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 24, 2020. . https://doi.org/10.1101/2020.07.24.20161315 doi: medrxiv preprint outcomes due to covid-19 to the general public to help people clearly understand their risks and steps they can take to minimize this risk. future research can seek to better understand why younger adults are experiencing high anxiety. since such high level of anxiety among the young population was not mediated by their perceived risk for getting covid, being admitted to icu or dying from covid, it is possible that their anxiety is related to social isolation, loneliness, loss of income/employment opportunities or exposure to social media during covid outbreak (dryhurst et al., 2020) . population-level interventions (e.g. at educational institutes and workplaces) targeted at prevention and management of anxiety can help to reduce its serious or long-term sequel and are urgently required. telehealth and online mental health consultations can be used to address the immediate mental health needs of the public. a limitation of our study is that due to its cross-sectional design, we cannot infer causal relationship between perceived risk and anxiety. although, we used a convenience sample of adults, our results concur with studies from other countries showing high population-level anxiety (qian et al., 2020) . in conclusion, we find high anxiety among younger adults, those with chronic conditions, living with children and with low trust in the government response to control the outbreak. effective communication should adequately convey the accurate information on risk of dying due to covid-19 to address anxiety among public. interventions to manage anxiety among younger adults are critical to improve their overall well-being during this and any future infectious disease outbreaks. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 24, 2020. . https: //doi.org/10.1101 //doi.org/10. /2020 includes below primary, primary, secondary, vocational or diploma *includes chronic-lung condition, gastro-intestinal disease, neurological condition, back pain, osteoporosis, joint-pain, arthritis, rheumatoid disease or nerve pain or eye problems all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 24, 2020. . https://doi.org/10.1101/2020.07.24.20161315 doi: medrxiv preprint all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july 24, 2020. . https://doi.org/10. 1101 /2020 risk perceptions of covid-19 around the world subthreshold and threshold dsm-iv generalized anxiety disorder in singapore: results from a nationally representative sample why does covid-19 disproportionately affect the elderly? psychological responses, behavioral changes and public perceptions during the early phase of the covid-19 outbreak in china: a population based cross-sectional survey anxiety, depression, traumatic stress, and covid-19 a brief measure for assessing generalized anxiety disorder: the gad-7 psychological impact of the covid-19 pandemic on health care workers in singapore key: cord-332733-rnq4z2yz authors: su, jinghua; chen, xiyuan; yang, ning; sun, meng; zhou, liang title: proximity to people with covid-19 and anxiety among community residents during the epidemic in guangzhou, china date: 2020-07-23 journal: bjpsych open doi: 10.1192/bjo.2020.59 sha: doc_id: 332733 cord_uid: rnq4z2yz the recent outbreak of a novel coronavirus pneumonia (covid-19) may have acute psychological consequences, both in relation to the impact of the virus itself and the restrictions imposed to tackle its spread. we conducted an online survey of 403 residents in guangzhou, china. we found the prevalence of anxiety (defined as generalized anxiety disorder–7 score ≥5) was 37.7%, and anxiety was significantly and moderately correlated with worry about covid-19. higher anxiety levels in community residents was associated with the presence of individuals with covid-19 in the same building; a longer time spent each day gathering information about the virus; and choosing social media as their preferred source of information. our findings provide an insight into the psychological support and guidance about information sources that are required in this type of public health emergency. at the end of 2019 a novel coronavirus pneumonia (covid-19) outbreak emerged in wuhan, hubei province, china, and spread rapidly to the rest of china and beyond, resulting in worldwide major public health concern. 1 to stop transmission of the virus, urgent measures were put in place by the chinese government, 2 such as the prolongation of the spring festival vacation, strict traffic control and the demand that the public stay at home. as the number of confirmed cases and deaths increased sharply and unprecedented isolation demands were imposed on the public there was an urgent need to examine the psychological impact on the public of the outbreak and the factors associated with it. an outbreak of contagion usually has psychological consequences among the population. the 2003 outbreak of severe acute respiratory syndrome led to social disengagement, mental stress and anxiety, which subsequently led to a higher suicide rate in hong kong. 3 a most recent survey in china during the covid-19 epidemic revealed that the prevalence of depression and anxiety was 50.6% and 44.7%, respectively, among 1563 medical staff. 4 however, little is known about the psychological impact on the public so far. community residents are required to follow a series of strict isolation demands, such as mandatory mask wearing, discontinuation of all forms of gathering and staying at home as far as possible. in the meantime, with the rise of the internet and smart phones, an enormous amount of information is flooding into people's lives through social media including for example wechat, weibo and tik tok. timely reports about the epidemic can help the public to avoid areas where there are more people with the virus. however, information overload may be a risk factor for anxiety. the aim of this survey was to explore the prevalence of anxiety among community residents in guangzhou city, the third biggest city in china, and its association with proximity to people with covid-19, information overload and information sources. on 7 february 2020, there were 298 confirmed covid-19 cases in guangzhou. data was collected from two housing compounds (ky and hl) that had newly confirmed cases in the 5 days before the survey, and one housing compound (df) without any confirmed or suspected cases. individuals were eligible to participate if they lived in one of the three selected communities, were aged 18 or above and had no family members diagnosed with covid-19. one wechat group of residents was selected in each housing compound. we distributed a non-transmissible link to the questionnaire in these three wechat groups and invited group members to participate in the survey. the survey was conducted between 7 and 8 february 2020. all participants had to read the informed consent and agree to participate before they could start the survey. this study was approved by the institutional ethics committee of the affiliated brain hospital of guangzhou medical university. we collected data on participants' demographic characteristics, proximity to covid-19 cases, time spent collecting information about coronavirus, favourite methods to obtain information, worry about covid-19 and anxiety. proximity to covid-19 was set as high (people with covid living in the same building), medium (people with covid living in the same housing compound but not in the same building) and low (no people with covid in the same housing compound). time spent on collecting information about coronavirus referred to daily time used in collecting information relating to covid-19, including television, newspaper, radio, websites, social * joint first authors. media. a single item 'in general, do you worry about the current situation of covid-19?' was used to evaluate the degree of worry. four options were provided ranging from 'very worried' to 'not at all'. generalized anxiety disorder (gad-7), a brief self-rated scale validated in a chinese population and commonly used in online surveys, was used to evaluate participant' anxiety level in the past 2 weeks. 5, 6 there are seven items and the total score ranged from 0 to 21, with higher scores indicating severer anxiety. the total scores on the gad-7 were categorised into no anxiety (0-4), mild anxiety (5-9), moderate anxiety (10-14) and severe anxiety symptoms (≥15). 7 descriptive analyses were used to describe the demographic characteristics and prevalence of anxiety. spearman's correlation was performed to probe the correlation between worry about covid-19 and anxiety. ordinal logistic regression was performed to explore factors associated with participants' anxiety levels. all analyses were conducted using spss version 22. a total of 1420 residents from three wechat groups were approached, and 539 participants completed the questionnaire. in total, 136 were excluded because they were aged under 18, were not from the three sample housing compounds or had family members diagnosed with covid-19. finally, 403 participants were included in the analyses (response rate 28.4%). twenty-eight participants who did not know that there were confirmed cases in their housing compound were classified into the group with no confirmed cases. the mean age of the 403 participants was 42 (s.d. = 11.2) years, 68.5% were women, 87.3% were married and 79.7% had a college education or higher. the mean score on the gad-7 was 4.4 (s.d. = 4.8). the prevalence of anxiety was 37.7% (152/403); 23.1% had mild anxiety, 9.7% had moderate anxiety and 5.0% had severe anxiety. significant and moderate correlation was found between worry about covid-19 and gad-7 scores (r = 0.545, p < 0.001). proximity to patients with covid-19, time spent on collecting information about coronavirus and preferring to use social media as their information source were included in the multivariate analysis. demographic characteristics including age, gender, marital status, education level and family income were also included. table 1 shows that after controlling for demographic characteristics, the presence of cases of covid-19 in the same building, spending more than 2 h each day collecting information about covid-19 and preferring to use social media as their information source were significantly associated with anxiety, whereas no significant association was found between all demographic characteristics and anxiety. in this study, we focused on anxiety symptoms rather than on anxiety disorder because with anxiety symptoms interventions are possible at the community level. anxiety was highly prevalent and is significantly correlated to worry about covid-19 during the peak period of the covid-19 outbreak. in a previous survey of 8917 community residents in shanghai in 2014, only 7.8% reported gad-7 scores of 5 or higher, much lower than that in our study. 8 the moderate correlation between anxiety and worry about covid-19 indicates that the elevated anxiety among community residents is likely a consequence of the covid-19 epidemic. anxiety was not associated with demographic characteristics in our study, which indicates the impact of the covid-19 epidemic may be universal in community residents. the presence of people with covid-19 in the same building was associated with anxiety. this may be a reasonable emotional response to actual threat. there have been several news reports of multiple cases on different floors and in different apartments in the same buildings. although individuals with confirmed/suspected cases were admitted to hospital immediately after being identified, more social and psychological support is needed for those who live in the same building. spending more than 2 h per day collecting information related to covid-19, particularly through social media, was associated with anxiety. our results are similar to findings from a previous study that indicated that post-traumatic stress is associated with indirect exposure to 9/11 through media. 9 social media often reports unconfirmed and/or unofficial news that may increase anxiety. advice about an appropriate amount of time to spend collecting information through reliable sources should be given. there are several limitations to our study. first, this is not a representative sample. socioeconomic status is high among residents of the selected housing compounds. hence, the prevalence of anxiety in our study is not generalisable. second, we did not include other factors such as pre-existing mental disorders that may be related to anxiety. third, the cross-sectional nature of this study prevents examination of causality. in conclusion, people who are experiencing higher levels of anxiety may spend more time collecting information about covid-19. a novel coronavirus from patients with pneumonia in china timely mental health care for the 2019 novel coronavirus outbreak is urgently needed the impact of epidemic outbreak: the case of severe acute respiratory syndrome (sars) and suicide among older adults in hong kong the mental health of medical workers in wuhan, china dealing with the 2019 novel coronavirus reliability and validity of a generalized anxiety disorder scale in general hospital outpatients prevalence and socio-demographic correlates of psychological health problems in chinese adolescents during the outbreak of covid-19 a brief measure for assessing generalized anxiety disorder: the gad-7 emotional problems and service needs of community residents nationwide longitudinal study of psychological responses to l.z. designed the study and wrote the protocol. j.s., n.y. and x.c. collected the data. j.s. undertook the statistical analysis and wrote the first draft of the manuscript and worked with l.z., x.c. and m.s. on final preparation. none.icmje forms are in the supplementary material, available online at https://doi.org/10.1192/bjo. 2020.59 key: cord-310592-he6wquwj authors: drummond, lynne m. title: does coronavirus pose a challenge to the diagnoses of anxiety and depression? a view from psychiatry date: 2020-09-03 journal: bjpsych bulletin doi: 10.1192/bjb.2020.102 sha: doc_id: 310592 cord_uid: he6wquwj some authors have suggested that the emergence of the novel coronavirus, sars-cov-2, and the subsequent pandemic has meant that the constructs of pathological anxiety and depression are meaningless owing to widespread anxiety and depressive symptoms. this paper examines what is required to make a diagnosis of a depressive or anxiety disorder and how this may differ from fleeting symptomatology in response to specific situations or stimuli. all people experience the emotions of both anxiety and depression, but far fewer have a persistent anxiety or depressive syndrome which interferes with their quality of life and functioning. the pandemic and its issues are then discussed, and existing studies examining the reactions of people living through the pandemic are presented. finally, the paper examines possible ways to cope at times of increased stress and how we can try to protect ourselves from long-term mental health sequelae of chronic stress. one of the challenges of conducting studies to examine the prevalence and frequency of anxiety and depression is that these terms describe symptoms rather than a diagnosis. everyone has experienced these as symptoms at some point in their lives. diagnoses are made on the basis of a recognised cluster of symptoms associated with anxiety and depression. one of the difficulties is that these terms are also used in general parlance to describe short-lived emotional changes which can occur as an emotional reaction to a stimulus or event, rather than a full-blown syndrome that affects the individual's quality of life. indeed, if we as a species did not experience anxiety responses in threatening situations, we would undoubtedly have become extinct as we walked over cliff edges, faced up to dangerous carnivores, or generally partook in dangerous and risky behaviour. levels of anxiety and depression also vary between individuals without necessarily being pathological. for example, we will all know some members of our social circle who are thrill-seekers and attracted to danger, whereas others are much more risk averse. similarly, some people seem to be happy and philosophical at all times, whereas others are more pessimistic and prone to feel low and miserable at the slightest upset. overall, therefore, population studies are fraught with difficulties in accommodating this area of potential self-reporting bias. for a diagnosis of anxiety disorder or depression to be made, an individual should be experiencing a range of symptoms associated with the anxiety and depression, and the symptoms should be apparent for a period of time (not just hours or minutes but weeks or months) and sufficiently severe that they interfere with the person's ability to function fully in their home, work, social or private leisure settings. the consistency of the emotional symptoms is inherent in diagnostic instruments such as the icd, 1 and widely different prevalence figures may be obtained in self-report questionnaires unless the same criteria are applied. in medical and psychological parlance, stress is a physical, mental or emotional factor that causes bodily or mental tension. stresses can be external (from the environment, psychological factors or social situations) or internal (e.g. illness). stress, both recent and in childhood, is known to affect mental well-being. the coping ability of the individual affects whether or not stress results in deterioration of mental well-being. 2 different individuals subjected to similar trauma and stress do not all react in the same way; whereas some will experience lasting symptoms, other will seem to have hardly any lasting sequelae. population studies examining the prevalence of anxiety and depression have demonstrated that these are among the most common conditions in diverse societies. the world health organization (who) estimated that in 2015 the prevalence of depression was 4.4% globally; however, this figure varied with gender, with women having a prevalence of 5.1% and men 3.6%. depression also increased with age in adulthood, peaking in both genders at age 55-74 years, and varied among different countries. the lowest rate of 2.6% was found in men in the western pacific region, and the highest rate of 5.9% in women in the african region. these rates of depression were found to have increased by 18.4% since 2005. 3 for anxiety, the prevalence was estimated to be 3.6%. as with depression, anxiety disorders are more common among females than males (4.6% compared with 2.6% at the global level). again, anxiety disorders were found to have increased since 2005 by 14.6%. as depression and anxiety are often comorbid disorders, it is not accurate to combine these two figures. 3 a recent large study in the uk examined adults for a range of physical and mental disorders (biobank uk). a questionnaire asking about mental disorders found that 21.2% had received a diagnosis of depression at some time in their lives and 14% had been diagnosed with anxiety. the sample who answered the questionnaire were not representative of the whole population, as the participants were aged 45-82 years, with 53% aged 65 or over, 57% were female and 45% had a degree (compared with census data in which 23% had a degree). 4 on 31 december 2019, the who was informed of an outbreak of pneumonia of unknown cause in wuhan city, in hubei province, china. it was then announced on 12 january 2020 that a novel coronavirus had been identified in samples from infected individuals. this virus was referred to as sars-cov-2 and the associated illness as covid-19. china acted by completely closing down wuhan and hubei province, but this was not before the virus seemed to have travelled widely globally. in the uk, people arriving from wuhan or those believed to have been in contact with sars-cov-2 were quarantined, but transmission within the uk and people affected by the virus who had not been abroad was first documented on 28 february 2020. the who declared a pandemic on 11 march. on 15 march, following observations of a larger outbreak in northern italy, the uk government asked people to work from home if possible, avoid unnecessary travel and avoid contact with others. anyone with symptoms suggestive of sars-cov-2 was asked to self-isolate, and those over the age of 70 years, pregnant women and people with underlying conditions were asked to self-isolate for at least 7 weeks. however, on 20 march, the four governments of the uk shut all schools, restaurants, pubs, indoor entertainment venues, non-food or nonessential shops, and banned people from meeting anyone they did not live with. people were prohibited from leaving their homes except for one period of exercise per day and to obtain essential food supplies or attend to medical needs. at all times, people were asked to stay at least 2 metres away from those they did not live with (social distancing). on 13 may 2020, some adjustments to the requirements were made in england only, with people being allowed to exercise as much as they wished and to drive to an area to exercise; everyone who could not work from home was urged to return provided they could remain at least 2 metres apart, and plans were made for children to return to school in june. the devolved governments of wales, scotland and northern ireland maintained their 'stay at home' policies. on 14 may 2020, the who reported 4 248 389 cases of covid-19 globally and a worldwide death toll of 292 046. 5 in the uk, as of 09:00 h on 23 may, over 35 000 people had died having tested positive for the virus, 6,7 although other sources state that the number of actual deaths of people with symptoms suggesting covid-19 was much as 55% higher than this number. 8 other countries worldwide have had varying numbers of cases and deaths, and widely differing responses to the pandemic. given that we are facing an unknown and unseen threat to our health and survival, it is unsurprising that there have been increased numbers of people complaining of symptoms of stress, anxiety and depression. a population survey of 1210 respondents from 194 cities in china found that 28.8% of respondents reported moderate to severe symptoms of anxiety, 16.5% reported moderate to severe depressive symptoms and 8.1% reported moderate to severe levels of stress. almost 85% were spending 20-24 h each day at home, and over 75% were worried about family members contracting covid-19. women, students and those who reported poorer general health were more likely to report distress. 9 among healthcare workers in china (over 60% from wuhan), a much higher proportion reported psychological symptoms, with over 70% suffering from distress, more than half having symptoms of depression, and over 44% having symptoms of anxiety. unsurprisingly, those working on the front line were more likely to report symptoms, as were those working within hubei province. 10 in a spanish population survey, 18.7% of the sample had depressive symptoms, 21.6% anxiety symptoms and 15.8% posttraumatic stress disorder symptoms. fewer symptoms were found among older people, those who were economically stable and those who felt they had adequate information about the pandemic. a greater number of symptoms were found in women and those who had symptoms consistent with the virus, and those who had a close relative with symptoms were more likely to report distress. reported loneliness was also predictive of more psychological symptoms. 11 a turkish study using the hospital anxiety and depression scale 12 and the health anxiety inventory health anxiety 13 found that almost 24% were above the cut-off to suspect depression, and more than 45% were above the threshold for anxiety. being a woman, living in an urban area and having a history of psychiatric disorder were found to be risk factors for anxiety, and being female and living in an urban area were risk factors for depression. women with chronic physical disease and a psychiatric history were at greater risk of health anxiety. 14 overall, it can be seen that anxiety and depression are normal emotions existing within the population and experienced to a greater or lesser extent by all people over time. the sars-cov-2 pandemic has led to great changes in our way of life, as well as a real fear that we and our loved ones may contract a potentially life-threatening disease. in addition, front-line workers, including healthcare workers, are under increasing stress and heavier workload. it is therefore not surprising that there is an increase in the symptoms of anxiety and depression in the general population, particularly in people working in front-line healthcare. in addition, many people have been indoors with restrictions on physical activity and an inability to visit friends and family. this is even more poignant and damaging as many are not able to be with loved ones at the end of their life and are unable to attend funerals. the national health service has issued guidance for the population to look after their mental health. this includes setting a structure to the day whether or not you are working, making time to speak to friends and family using remote methods, and looking after diet and exercise, as well as restricting the amount of new reporting an individual is watching if this is leading to distress. 15 preventive measures such as these may help to reduce some of the symptoms. indeed, structuring the day and including a balance of activities which give a sense of mastery as well as those that give pleasure can be helpful in combating depressive symptoms. 16 ensuring a good balanced healthy diet and adequate hydration, and avoiding smoking, alcohol and drugs are also useful in reducing anxiety and depressive symptoms. 16, 17 working on sleep hygiene and trying to get a good sleep at night using tried and tested methods can also be useful. 17 exercise is also important and known to be beneficial to our mental state 18 . extreme isolation such as that recommended in the uk for those aged over 70 years and those with severe pre-existing medical conditions may have a detrimental effect not only on physical health and the ability to withstand infection but also on mental health. overall, it can be seen that anxiety and depression are ubiquitous human emotions which occur in response to certain situations and stimuli. these symptoms are usually reversible once the situation changes. however, continued stress at this time may result in longer-term anxiety and depressive syndromes. there are some practical steps we can take to try to limit the effects of the current situation on our own mental health as well as that of our loved ones and our patients. world health organization. the icd-10 classification of mental and behavioural disorders: diagnostic criteria for research extending the vulnerability-stress model of mental disorders: three-dimensional npsr1 × environment × coping interaction study in anxiety world health organization. depression and other common mental disorders: global health estimates mental health in uk biobank -development, implementation and results from an online questionnaire completed by 157 366 participants: a reanalysis world health organization. situation report -115. who covid-19 daily deaths coronavirus cases in the uk: daily updated statistics how many people are dying of covid-19 in the uk? what is the official death toll and will care home deaths exceed hospital deaths? guardian immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019 mental health consequences during the initial stage of the 2020 coronavirus pandemic (covid-19) in spain the hospital anxiety and depression scale the health anxiety inventory: the development and validation of scales for the measurement of health anxiety and hypochondriasis levels and predictors of anxiety, depression and health anxiety during covid-19 pandemic in turkish society: the importance of gender depression generalised anxiety disorder and panic physical activity interventions in severe mental illness key: cord-270232-ln7iil5y authors: bergman, yoav s.; cohen-fridel, sara; shrira, amit; bodner, ehud; palgi, yuval title: covid-19 health worries and anxiety symptoms among older adults: the moderating role of ageism date: 2020-06-17 journal: international psychogeriatrics doi: 10.1017/s1041610220001258 sha: doc_id: 270232 cord_uid: ln7iil5y a prominent feature of anxiety in late life is concerns regarding physical health. anxiety symptoms among older adults have been connected with various psychological outcomes, including social isolation and loneliness. during the coronavirus disease 2019 (covid-19) pandemic, many societies have demonstrated increased ageist attitudes, encouraging older adults to distance themselves from society. accordingly, the current study examined the moderating role of covid-19-related ageism in the connection between covid-19 health worries and anxiety symptoms among older adults. data were collected from 243 older adults (age range 60–92; m = 69.75, sd = 6.69), who completed scales assessing covid-19-related health worries and ageism, as well as anxiety symptoms. the results demonstrated that both health worries and ageism were positively associated with anxiety symptoms. moreover, the connection between health worries and anxiety symptoms was more pronounced among older adults with high ageism levels. the study highlights the vulnerability of older adults in general, and ageist older adults in particular, to the negative consequences of covid-19-related health worries, and emphasizes the role of the increased ageist stance of society during the pandemic in this regard. anxiety symptoms and anxiety disorders constitute a major clinical issue in late life. the prevalence rate of anxiety disorders ranges from 1.2% to 15% among older adult populations (byrne and pachana, 2011) and is undoubtedly higher for anxiety symptoms which do not reach the diagnostic cutoff point. late-life anxiety has been associated with negative psychological outcomes, including loneliness and social isolation (fees et al., 1999) . a prominent characteristic of anxiety symptoms, which also constitutes a diagnostic criterion for general anxiety disorder (american psychiatric association, 2013) , is excessive and uncontrollable worry. while the causal connection between worries and anxiety is open to debate (see judah et al., 2013) , it is nevertheless suggested that the cognitive phenomenon of worry is central to the anxious experience and that a major feature of anxiety-related worries among older adults is concerns regarding physical health (diefenbach et al., 2001) . these concerns may be exacerbated by the coronavirus disease 2019 (covid-19) pandemic, which constitutes a particular threat to anxiety symptoms among older adults (girdhar et al., 2020) . according to ayalon (2020) , the covid-19 pandemic has been portrayed, from its initial stages, as a "problem of older adults," and the portrayal of older adults as a homogenous group which is particularly vulnerable to the coronavirus, sometimes even by government officials, has resulted in increased ageism around the world. accordingly, older adults are increasingly encouraged by society to isolate themselves from younger people, thereby creating an age distinction in the perception of the consequences of covid-19. this policy may support ageist beliefs regarding the need to limit intergenerational encounters and to impede the tendency of older adults to infiltrate into the identity of younger people (north and fiske, 2013) . additionally, according to levy's (2009) stereotype embodiment theory, older adults may internalize their ageist experiences and attitudes, which become self-definitions through which they see themselves and perceive their self-image (levy, 2009) . accordingly, as the need for social distancing is rationalized by the older adults' physical susceptibility to the coronavirus, ageist older adults may be more susceptible to the negative psychological consequences of covid-19 health-related worries, since such worries could implicitly link them with the social group of "older adults," which they avoid and devalue. accordingly, the current study aimed at examining the role of ageism in the connection between covid-19 health worries and anxiety symptoms among older adults and explored the moderating role of ageism as strengthening this connection. we hypothesized that both covid-19 health worries and covid-19-related ageism would be positively related with anxiety symptoms. moreover, we hypothesized that the health worries-anxiety symptoms connection-would be stronger among older adults who display high levels of ageism. participants and procedure data were collected from 243 jewish israelis and between march 16 and april 14, 2020. on the last day of collection, 12,361 people in israel had tested positive for covid-19, and 123 had died. age ranged from 60 to 92 (m = 69.75, sd = 6.69), and 75 participants (30.9%) were men. most of the participants (n = 177, 72.8%) reported that they were in a relationship. two participants (0.8%) had no formal education, 9 (3.7%) had some high-school education, 17 (7.0%) had a full high-school education, 35 (14.4%) had some undergraduate courses, and 179 (73.2%) had an academic degree. the majority of participants rated their economic status and health status as "pretty good" or above (n = 220, 90.2%; n = 216, 89.2%, respectively). the online questionnaire was distributed across multiple social media. anonymity was guaranteed as identifying details were neither required nor requested. the study scales were back-translated into hebrew by two experienced bilingual psychologists. the study received ethical approval by the institutional review board of [blinded for review]. participants completed background characteristics, including age, gender, marital status, education (rated from 1, "without formal education" to 6, "formal university degree"), and economic and health status (rated from 1, "not good at all" to 5, "very good"). we also examined exposure to covid-19, calculated as the sum score of six different types of exposure, and behavioral changes due to the pandemic, calculated as the sum of 11 changes in the individual's behaviors. both exposure and behavior changes were dichotomous (0 = "no," 1 = "yes"; for details, see table s1 published as supplementary material online attached to the electronic version of this paper). participants completed the following measures while referring directly to feelings and symptoms they experienced since the covid-19 outbreak. for means, sds, and correlation matrix for the study variables, see table s2 published as supplementary material online attached to the electronic version of this paper. covid-19 worries were examined with four items, rated on a scale ranging from 1 ("not concerned at all") to 5 ("extremely concerned"). a mean score was calculated, and higher scores reflect higher levels of health concerns. cronbach's alpha was .83 (for details regarding the items used to assess covid-19 worries and ageism, see appendix a1 published as supplementary material online attached to the electronic version of this paper). ageism was assessed with seven items taken from north and fiske's (2013) scale, which were adapted to examine ageist attitudes during the coronavirus pandemic. we chose to focus on items pertaining to fear of intergenerational segregation and social identity infiltration (north and fiske, 2013) due to our wish to keep the study questionnaires brief on the one hand, while keeping them relevant to covid-19 concerns on the other hand. participants rated their responses a scale ranging from 1 ("strongly disagree") to 6 ("strongly agree"). a mean score was calculated, and higher scores reflect higher levels of ageism. this scale has demonstrated strong internal consistency (north and fiske, 2013) , and in the current study, cronbach's α was .76. anxiety symptoms were assessed with the sevenitem generalized anxiety disorder scale (spitzer et al., 2006) . participants rated their symptoms (e.g. "feeling nervous, anxious, or on edge") during the last two weeks on a four-point scale (0="not at all" to 3="almost every day"). ratings were summed with higher scores reflecting increased anxiety. internal reliability was good (cronbach's α = .89). analyses were conducted using the spss-25 software (ibm), and significant interactions were probed using model 1 of the process 3.4 macro (hayes, 2018) , which calculates the regression coefficients for the effects of the predictor (i.e. covid-19 worries) on the predicted (i.e. anxiety symptoms) variable for both ±1 sd of the moderator (i.e. ageism). a hierarchical regression was conducted in order to examine the study hypotheses, with anxiety symptoms as the predicted variable. the first step included the socio-demographic and covariate factors of participants' age, gender, relationship status, education level, economic status, self-rated health, covid-19 exposure, and covid-19 behavioral changes. the second step included covid-19 worries and ageism, and the third and final step included the covid-19 worries × ageism interaction (see table 1 for regression coefficients). a power analysis for detecting a medium to strong effect size (0.20) with 11 predictors required a sample size of 178, indicating that the current sample was sufficient for examining the study model. potential multicollinearity between the predicting variables was rejected, as the values of both tolerance and variance inflation factor for the study variables ranged between 0.71 and 0.96, and between 1.04 and 1.39, respectively. as table 1 demonstrates, covid-19 health worries (b = 1.55, se = .27, β = .36, p < .001) and ageism (b = 1.01, se = .47, β = .13, p < .05) were positively related with anxiety symptoms, which is in line with the first hypothesis. the second hypothesis was also confirmed, as a significant interaction covid-19 health worries × ageism was discovered (b = .52, se = .22, β = .15, p < .05), accounting for an additional 1.9% of variance (total r² = .259). upon probing the interaction with process (hayes, 2018) , we discovered that while the association between health worries and anxiety symptoms remained significant for individuals with both low and high ageism levels, this association was significantly stronger among individuals with high ageism (b = 2.13, se = .36, β = .49, p < .001) in comparison to those with low ageism (b = 1.07, se = .33, β = .25, p < .01; see figure 1 ). the results remained unchanged when the study model was examined without the covariates. anxiety symptoms among older adults are often characterized by health-related concerns. these concerns may be exacerbated due to the current covid-19 pandemic, and by increased ageist views following the pandemic, demonstrated by the social distancing policy aimed at older adults. our results demonstrate that both covid-19 health-related worries and ageism resulting from the current pandemic were positively associated with anxiety symptoms among older adults. moreover, the connection between covid-19-related health worries and anxiety symptoms was stronger among individuals with high levels of ageism. in fact, while the mean difference in anxiety symptoms between individuals with high worries and low/high ageism (m = 3.61 vs. 5.47, respectively) seems modest, it is quite important, when one takes into account that the cutoff point for mild anxiety is 5 (spitzer et al., 2006) , covid-19 health worries, anxiety, and ageism 3 indicating that older adults with high ageism and covid-19 worries meet the clinical threshold for mild anxiety. in line with the stereotype embodiment theory (levy, 2009) , older adults with high levels of ageism (i.e. self-ageist older adults) may perceive their health both reduced and prone to threats and may therefore be at a higher risk for displaying a stronger connection between the covid-19 health concerns and anxiety symptoms. this could also stem from the fact that such individuals' anxiety is exacerbated, since they experience covid-19 worries in connection with the social group of "older adults," toward which they are reluctant. moreover, in light of the importance of meaningful social relationships for older adults (carstensen et al., 1999) , it is possible that ageist older adults may be particularly at risk for negative psychological consequences during the pandemic. while the current study did not examine older adults' perceptions of the covid-19 physical age-related separation restrictions, encouraged at times not only by society but by government officials (ayalon, 2020) , future studies can examine the additive value of such perceptions to the explained variance of anxiety symptoms. several limitations should be mentioned. first, the cross-sectional nature of the data precludes the ability to establish causality. namely, it is not clear whether covid-19 worries produce anxiety symptoms, or vice versa. accordingly, longitudinal designs are needed to further validate our findings. second, due to the online nature of the study, it is possible that older adults who are less computer-proficient were precluded from taking part in the study, and it is important to examine the results using additional data gathering methods. moreover, while we assumed that older individuals who participate in an online study would not demonstrate significant cognitive difficulties, we did not examine this issue. additionally, we assessed ageism with an adapted short version of north and fiske's scale, and examining additional aspects of ageism (e.g. consumption; see north and fiske, 2013) may provide a deeper understanding of its role regarding health concerns and anxiety symptoms. finally, we did not assess pre-pandemic health worries, anxiety symptoms, and ageism and therefore could not control for possible changes in the levels of all three variables among the participants. nevertheless, our study highlights how the rise in ageism during the covid-19 pandemic poses additional difficulties for older adults, beyond the understandable concerns and uncertainty we all face. while research has addressed the effect of covid-19 on older adults (e.g. lopez et al., 2020) , to the best of our knowledge, this is the first attempt to examine the connection between health worries, anxiety symptoms, and ageism in the context of the pandemic. there is little doubt that physical distancing constitutes a key factor in controlling the outbreak of covid-19. however, a continuous effort is required to understand the social implications of this phenomenon on older adults, which may not only result in increased worry, but in increased anxiety and psychological distress. none. all five researchers were responsible for the concept and study design. dr. bergman wrote the paper; dr. cohen-fridel, prof. bodner, and prof. palgi collected the data, and prof. shrira analyzed the data. to view supplementary material for this article, please visit https://doi.org/10.1017/s1041610220001258 diagnostic and statistical manual of mental disorders (dsm-5®) there is nothing new under the sun: ageism and intergenerational tension in the age of the covid-19 outbreak development and validation of a short form of the geriatric anxiety inventory -the gai-sf taking time seriously: a theory of socioemotional selectivity worry content reported by older adults with and without generalized anxiety disorder a model of loneliness in older adults managing mental health issues among elderly during covid-19 pandemic an introduction to mediation, moderation, and conditional process analysis: a regression-based approach the prospective role of depression, anxiety, and worry in stress generation stereotype embodiment: a psychosocial approach to aging psychological well-being among older adults during the covid-19 outbreak: a comparative study of the young-old and the old-old adults a prescriptive intergenerational-tension ageism scale: succession, identity, and consumption (sic) a brief measure for assessing generalized anxiety disorder: the gad-7 key: cord-284030-hnjhdlif authors: li, quanman; miao, yudong; zeng, xin; tarimo, clifford silver; wu, cuiping; wu, jian title: prevalence and factors for anxiety during the coronavirus disease 2019 (covid-19) epidemic among the teachers in china date: 2020-08-13 journal: journal of affective disorders doi: 10.1016/j.jad.2020.08.017 sha: doc_id: 284030 cord_uid: hnjhdlif abstract objective to assess the prevalence of anxiety and explore its factors during the coronavirus disease 2019 (covid-19) epidemic among the teachers in china. methods we involved 88611 teachers (response rate: 94.75%) from three cities of henan province, china, during february 4, 2020 and february 12, 2020. anxiety was assessed by using generalized anxiety disorder tool (gad-7). odds ratios (or) with 95% confidence intervals (ci) for potential factors of anxiety were estimated using multiple logistic regression models. results the overall prevalence of anxiety was 13.67%. the prevalence was higher for women than men (13.89% vs. 12.93%). the highest prevalence of anxiety was 14.06% (se 2.51%) with age of 60 to 100 years in men, and 14.70% (se 0.56%) with age of 50 to 60 years in women. participants located in country-level city school had the lowest prevalence of anxiety across all age categories (12.01% for age of 18-30 years; 12.50% for age of 30-40 years; 12.13% for age of 40-50 years; 9.52% for age of 60-100 years). after adjusting for potential confounders, age, sex, education status, type of teachers, school location, information source, worried level, fear level, and behavior status were found to be associated with anxiety. conclusions this large-scale study assessed the prevalence of anxiety in teachers, as well as its potential influence of factors, which is useful for international and national decision-makers. on december 30, 2019, wuhan became the center of an outbreak of the zoonotic coronavirus disease 2019 (covid-19) (zhu et al., 2020) . subsequently, the number of confirmed cases was a rapid increase in provinces in china which have developed economies and adjacent to hubei province lai et al., 2020) . then, confirmed cases of covid-19 were consecutively occurred in all provinces, municipalities, and special administrative regions in china (hoehl et al., 2020) and appeared to be expanding kamel et al., 2020) . finally, the outbreak was declared a public health emergency of international concern (pheic) on january 30, 2020 by the world health organization (who). however, the human-to-human transmission of covid-19 has been evolving since then. the infection even spread across other countries around the world (holshue et al., 2020; livingston and bucher et al., 2020; young et al., 2020) . on march 11, 2020, who had to announce that covid-19 could be described as a controllable pandemic. because of the rapid spread of severe acute respiratory syndrome coronavirus 2 (sars-cov-2), it therefore incurs substantial losses not only on global economy and trade but also posing the great challenges on medical and health services (phelan et al., 2020) . the burden of disease in terms of years lived with disability (yld) attributable to anxiety disorders relatively increased by 14.8% from 2005 to 2015, ranking ninth in the world (gbd 2015 disease and injury incidence and prevalence collaborators, 2016) . in addition, anxiety disorders may increase the risk of cancer, cardiovascular disease, and even mortality (batelaan et al., 2016; miloyan et al., 2016; wang et al., 2019) . previous study has revealed individuals with high health anxiety are prone to misinterpreting harmless bodily sensations and changes as evidence that they are infected in the context of a viral outbreak or pandemic, this will, in turn, increase their anxiety, influence their ability to make rational decisions, and impact their behavior (asmundson and taylor, 2020) . also, with the closure of schools, negative emotions experienced by teachers are compounded. the ongoing covid-19 epidemic maybe inducing anxiety for teachers. hence, a timely understanding of anxiety status is urgently needed. cost-effectiveness studies suggest that treatment alone is not sufficient to eliminate the disease burden attributable to anxiety disorders. another way to reduce the burden of anxiety disorders is to lower the incidence of new cases, which can be achieved through prevention rather than treatment (andrews et al., 2004; neil and christensen, 2009 ). so, we urgently draw the prevalence and risk factors of covid-19 in teachers. therefore, this present study included registered teachers in china during the covid-19 outbreak and aimed to assess the prevalence of anxiety and identify the potential risk and protective factors contributing to anxiety. this may assist government agencies and health-care professionals in safeguarding the psychological well-being of the school in the face of covid-19 outbreak expansion in china and different parts of the world. we adopted a cross-sectional survey design to assess anxiety in teachers during the epidemic of covid-19 by using an anonymous online questionnaire through an online survey platform ("surveystar", changsha ranxing science and technology, shanghai, china). a total of 93518 registered teachers (including primary school teachers, junior school teachers, high school teachers, and university teachers) were recruited by using a cluster sampling method from zhengzhou, xinyang, xinxiang city of henan province, china, during february 4, 2020 and february 12, 2020. for quality control, we excluded the participants aged<18 years or aged>100 years or those who took ≤100 seconds to fully respond to the questions (n=4907). ultimately, we included 88611 teachers (response rate: 94.75%) in this analysis. this study was approved by the ethics committee of zhengzhou university. all study participants consented for participation in this study. a standard questionnaire was developed to assess demographic characteristics (sex, age, marital status, and education level and so on), the knowledge about covid-19, attention, behavior, mental state (worry, fear, anxiety and so on), and other factors among all participants. attention of teachers to the epidemic were divided into 3 levels: high, moderate, and low. information source were classed as: independent learning (including wechat/weibo and tv/radio), structured learning (including documents issued by the government or schools) and mixed learning (including independent and structured learning). worried condition and fear among teachers on the epidemic were both divided into 3 levels: high, moderate, and low/none. all behavior (including "wearing a mask", "increasing the frequency of hand washing", "going out for dinner", "canceling the spring festival travel plan") were correctly, the behavioral status as high; part questions were answered correctly, the behavioral status as moderate; all questions were answered incorrectly, the behavioral status as low. anxiety was assessed by using the generalized anxiety disorder tool (gad-7) which has a sensitivity of 89% and specificity of 82%. a score of 10 or greater was considered a reasonable cut point for identifying cases. cut points of 5, 10, and 15 might be interpreted as representing mild, moderate, and severe levels of anxiety on the gad-7 (spitzer et al., 2006) . categorical data are represented as frequency (%) and were compared using pearson chi-squared test. means and standard deviations (sd) were used to present continuous data and were compared by student's t-test or analysis of variance. multiple logistic regression models were used to estimate odds ratios (ors) and 95% confidence intervals (cis). we developed three models: 1) unadjusted; 2) adjusted for sex, education status, type of teachers, school location, married status, attention level, information source, worried level, fear level, behavior status; and 3) adjusted for age, sex, education status, type of teachers, school location, married status, attention level, information source, worried level, fear level, behavior status. all analyses were performed by using sas v9.4 (sas inst., cary, nc) for windows. all statistical tests were two-sided, with p<0.05 considered statistically significant. among 88611 (23.07% men) teachers included 12110 teachers were shown to have anxiety disorder during the outbreak of covid-19 in china. the age of participants was 36.22 (sd 9.02) years. table 1 shows the characteristics of participants by anxiety status. as compared to participants without anxiety, participants with anxiety were different from the proportion of sex, education status, type of teachers, school location, married status, attention level, information source, worried level, fear level, and behavior status (all p<0.05). the overall anxiety prevalence was 13.67% (se 0.12%) during covid-19 pandemic in china. the prevalence was higher for women than men (13.89% vs. 12.93%). figure 1 showed the prevalence of anxiety in participants by age and sex. the highest prevalence of anxiety was 14.06% (se 2.51%) with age between 60 and 100 years in men, and 14.70% (se 0.56%) with age between 50 and 60 years in women. the lowest prevalence of anxiety was 12.36% (se 2.89%) found in participant with the age between 40 and 50 years in men, and 11.76% (se 4.30%) with age of between 60 and 100 years in women. participants located in county-level city school have the lowest prevalence of anxiety in almost age groups (12.01% for age of 18-30 years; 12.50% for age of 30-40 years; 12.13% for age of 40-50 years; 9.52% for age of 60-100 years) ( figure 2 ). similarly, teachers with low/none fear level showed a protective effect against the anxiety disorders compared to those with those with high level of fear (or 0.06 [95% ci 0.05-0.06]). detail information were showed in table 2 . further, participants at all age categories indicated high proportion of minimal anxiety level (49.89%, 47.27%, 48.33%, 50.83%, and 52.67%). mild anxiety was most prevalent (38.73%) in 30-40 age group. prevalence of severe anxiety for participants aged 18-30, 30-40, 40-50, and 50-60 years were 4.07%, 4.50%, 4.18%, and 4.91%, respectively. the proportion with moderate anxiety at the age of 60-100 years was the lowest (7.41%). and for minimal anxiety, the proportion of participants with age of 60 to 100 years was the highest (52.67%) and 30 to 40 years was the lowest (47.27%); for mild anxiety, age of 30 to 40 years was the highest (38.73%) and 60 to 100 years was the lowest (33.74%); for moderate anxiety, age of 30 to 40 years was the highest (9.50%) and 60 to 100 years was the lowest (7.41%); for severe anxiety, age of 60 to 100 years was the highest (6.17%) and 18 to 30 years was the lowest (4.07%) (supplementary materials figure 1) . the detail characteristics of participants by different level of anxiety were showed in supplementary materials table 1 : the proportion of sex, education status, type of teachers, school location, married status, attention level, information source, worried level, fear level, behavior status were all different in different levels of anxiety (all p<0.05). our study provided the prevalence of anxiety disorder in teachers during the covid-19 epidemic. the overall anxiety prevalence was 13.67% (13.89% for women and 12.93% for men). age, sex, education status, type of teachers, school location, information source, worried level, fear level, and behavior status were found to be associated with anxiety. however, we found the prevalence of anxiety in teachers reaching up to 13.67% (about 2.74 times) in this survey. the higher prevalence may pose potential risk during the epidemic of covid-19, such as, excessive consumption of medical resources (asmundson and taylor, 2020) . the data from british survey found that 16% of the population suffered from some form of anxiety (hale, 1997) . similarly, anxiety affect more than 40 million adults in the united states alone, about 18% of the population (torpy et al., 2011) . the evidence of meta-analysis has discovered the global current prevalence of anxiety disorders adjusted for methodological differences was 7.3% (95%ci 4.8-10.9%) (baxter et al., 2013) . our study suggested that anxiety may affect more population and the burden of anxiety may have a sharp increase in the world during this pandemic. as is supposed above, the global may also face great challenges work of mental health. as the previous studies, our study also suggested that the socio-demographic factors such as age, sex, education status were associated with anxiety (lejtzen et al., 2014) . in addition, we further found that type of teachers, school location, information source, worried level, fear level, and behavior status were associated with anxiety disorder. sherina et al. suggested that familiar stressful life events, such as loss, unemployment, and work-related, family, and housing problems, were associated with anxiety in primary care patients (tait and berrisford, 2011). all teachers in henan province were facing problems coping with new ways of working when we started the survey. as the epidemic spreads to other countries around the world, similar situation may be expected to happen. so our study may provide clues about the prevalence of anxiety and its factors. however, further studies about other occupations are needed to assess the stability and reliability of our results. we also found a worrisome result that there was a significant proportion of participants aged between 60 and 100 years who presented severe anxiety level. these teachers may face the risk of insufficient incomes at their retirement stage, due to excessive expenditure on treatment for anxiety. therefore, we suggest that the decision-makers of health services should pay more attention to the burden of anxiety among elderly individuals, especially during the outbreak of disease. our study has several strengths. to our knowledge, this is the large sample size study of teachers exploring the prevalence of anxiety. secondly, we used the standardized questionnaire (gad-7) to diagnose anxiety. thirdly, our results inform which teachers are most likely in need of psychosocial support. finally, we excluded the participants who not meeting the requirements of this study to make our results more realistic. nevertheless, some limitations should be considered. first, although we adjusted two models for many important covariates, there is still a possibility of residual confounding. further studies are needed to assess those relations and confirm the stability of these results. second, we did not explore the underlying mechanisms existing among covariates. future experimental studies are needed. thirdly, our study was designed as a cross-sectional survey, which does not establish causality. finally, participants of this study were all teachers, which may limit the generalizability of our findings to other professional population. the condition of the prevalence of anxiety was not optimal during the covid-19 epidemic among the teachers in china. factors including age, sex, education status, type of teachers, school a novel coronavirus from patients with pneumonia in china mapping the changing internet attention to the spread of coronavirus disease 2019 in china severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and corona virus disease-2019 (covid-19): the epidemic and the challenges evidence of sars-cov-2 infection in returning travelers from wuhan, china. the new england journal of medicine visualising the expansion and spread of coronavirus disease 2019 by cartograms geographical tracking and mapping of coronavirus disease covid-19/severe acute respiratory syndrome coronavirus 2 (sars-cov-2) epidemic and associated events around the world: how 21st century gis technologies are supporting the global fight against outbreaks and epidemics first case of 2019 novel coronavirus in the united states. the new england journal of medicine coronavirus disease 2019 (covid-19) in italy epidemiologic features and clinical course of patients infected with sars-cov-2 in singapore the novel coronavirus originating in wuhan, china: challenges for global health governance global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the global burden of disease study anxiety and new onset of cardiovascular disease: critical review and meta-analysis. the british journal of psychiatry : the journal of mental science anxiety disorders and all-cause mortality: systematic review and meta-analysis. social psychiatry and psychiatric epidemiology depression and anxiety in relation to cancer incidence and mortality: a systematic review and meta-analysis of cohort studies. molecular psychiatry how health anxiety influences responses to viral outbreaks like covid-19: what all decision-makers, health authorities, and health care professionals need to know utilising survey data to inform public policy: comparison of the cost-effectiveness of treatment of ten mental disorders. the british journal of psychiatry : the journal of mental science efficacy and effectiveness of school-based prevention and early intervention programs for anxiety a brief measure for assessing generalized anxiety disorder: the gad-7. archives of internal medicine abbreviations: ci, confidence interval; or, odds ratio adjusted for sex, education status, type of teachers, school location, married status, attention level, information source, worried level, fear level adjusted for age, sex, education status, type of teachers, school location, married status, attention level, information sour ce this study is supported by the national key r&d program of china (grant nos. 2018yfc0114501); zhengzhou university 2020 special project of discipline construction (grant nos. xkzdqy202007); henan medical education research project (wjlx2018008). the authors declare that they have no conflict of interest. location, information source, worried level, fear level, and behavior status may be considered as part of the overall management of anxiety. key: cord-276831-1z27qsym authors: zhu, juhong; sun, lin; zhang, lan; wang, huan; fan, ajiao; yang, bin; li, wei; xiao, shifu title: prevalence and influencing factors of anxiety and depression symptoms in the first-line medical staff fighting against covid-19 in gansu date: 2020-04-29 journal: front psychiatry doi: 10.3389/fpsyt.2020.00386 sha: doc_id: 276831 cord_uid: 1z27qsym background: the outbreak of novel coronavirus pneumonia (covid-19) has brought enormous physical and psychological pressure on chinese medical staff. it is extremely important to understand the prevalence and influencing factors of anxiety and depression symptoms in first-line anti-epidemic medical staff and their coping styles for these negative emotions. methods: a cross-sectional survey was conducted in gansu (china), with a questionnaire packet which consisted of the self-rating anxiety scale (sas), self-rating depression scale (sds), and the simplified coping style questionnaire (scsq). a total of 79 doctors and 86 nurses participated in the survey. correlation analysis was performed to explore the relationship between sas, sds, and scsq score. a linear regression model was used to determine the influencing factors for anxiety or depression symptoms. results: the prevalence rates of anxiety and depression symptoms among doctors was 11.4% and 45.6%, respectively. history of depression or anxiety (t=-2.644, p= 0.010, 95%ci: -10.514~-1.481) was shown to be a risk factor for anxiety symptoms in doctors, while being male (t=2.970, p=0.004, 95%ci: 2.667~13.521) was a protective factor for depression. the prevalence rate of anxiety and depression symptoms among nurses was 27.9% and 43.0%, respectively. history of depression or anxiety was a common risk factor for anxiety symptoms (t=-3.635, p=0.000, 95%ci: -16.360~-4.789) and depression symptoms (t=-2.835, p=0.005, 95%ci:-18.238~-3.254) in nurses. the results of partial correlation analysis (controlled for gender and history of depression or anxiety) indicated that the total score of positive coping was negatively correlated with the total score of anxiety (r=-0.182, p=0.002) and depression (r=-0.253, p=0.001). conclusions: the first-line anti-epidemic medical staff have high anxiety and depression symptoms and adopting positive coping styles will help to improve their negative emotions. since mid-december of 2019, coronavirus disease 2019 (covid-19) has been spreading from china (wuhan) to 26 countries worldwide (1) . as of february 24 th , 41600 medical staff across the country have been fighting in the front line of the anti-epidemic campaign. of these medical staff, 3387 of them were infected with the novel coronavirus pneumonia, accounting for 4% of all confirmed cases, while 22 were killed and accounted for 0.8% of the deaths. the front-line medical staff will not only bear the work pressure of overload, but also face the huge risk of infection (2) . stress represents the main environmental risk factor for psychiatric illnesses, and in a long-term stress state, people can be more prone to depression or other mental disease (3) , which will also increase the risk of infection (4) (5) (6) . therefore, it is necessary to investigate the psychological state of the first-line anti-epidemic medical staff and give them necessary psychological interventions if they have anxiety or depression. this cross-sectional study was conducted between february 1, 2020 and february 29, 2020. the research objects were the first line medical staff in the designated hospitals and fever clinics of novel coronavirus pneumonia in gansu province. the inclusion criteria were as follows: 1) 18 years or older; 2) doctor or nurse; 3) first-line to covid-19; 4) without serious mental illness, such as schizophrenia or an intellectual disability; 5) without physical disease affecting anxiety or depression, such as hypothyroidism or coronary heart disease; and 6) willing to be investigated. exclusion criteria were as follows: 1) less than 18 years old, 2) non-frontline medical or administrative staff, 3) not in gansu, 4) serious mental illness or a combination of disorders that may affect anxiety or depression, and 5) refused to be investigated. finally, 165 front-line medical staff working in the wuhan isolation ward were enrolled in the study. ethical approval was issued by the ethics committee of the second clinical medical college of lanzhou university, and all the participants had signed an informed consent before the study was initiated. by using the self-designed questionnaire, we have obtained the general demographic information of the respondents, including gender, age, marriage, occupation, education level, specialty, level of worry, and level of expectation. the self-rating anxiety scale (sas) (7) and self-rating depression scale (sds) (8) were used to assess anxiety and depression symptoms of medical staff respectively. both sas and sds are 20-item likert and norm-referenced scales, in which items tap physiological and psychological symptoms and are rated by participants according to how each applied to them within the past week, using a 4-point scale ranging from 1 (none, or a little of the time) to 4 (most, or all of the time) (9) . the choice of sas items is based on diagnostic criteria listed in the major american psychiatry literature, whereas the sds taps depressive symptoms based on factor analytic studies of depression symptoms (9) . the zung self-rating anxiety/depression scale (sas/sds) has been widely applied in clinical institutions and scientific research, showing convincing results and a remarkable degree of consensus among clinicians (10) . according to the conclusion of other studies (11), we also utilized the standard score of 50 as the critical value to divide depression or anxiety in the present study. the simplified coping style questionnaire (scsq) (12) is a 20-item self-report scale that includes two dimensions. the first entry consists of 1-12 items and reflects the traits of passive coping and active coping (8-item). the second entry consists of 13-20 questions, reflecting the traits of passive coping. this instrument has been commonly used in china and has proven to be highly reliable and valid (13) . in the current study, we used the electronic "questionnaire star" questionnaire as the survey tool, and information was collected through friend circle forwarding and wechat group promotion. "questionnaire star" is a professional online survey platform, which can be used for questionnaire surveys, evaluation, voting, and other purposes. compared with traditional survey methods, "questionnaire star" has the obvious advantages of being fast, low cost, easy to learn, and easy to use (14) . the categorical variables were expressed as the frequency (%), while the continuous variables were presented as mean± sd. a single sample kolmogorov-smirnov test was used to test whether the data conform to normal distribution. chi square test was used to compare categorical variables, while independent sample t-test and mann-whitney u test were respectively used to compare the continuous variables with and without normal distribution. the prevalence of anxiety and depression symptoms was calculated by splitting the total number of cases diagnosed by the total number of participants. the influence factors of anxiety or depression were analyzed by linear regression analysis. partial correlation analysis was used to analyze the correlation between scsq and sds/sas. the statistical analysis was performed by using spss version 22.0 and a p-value < 0.05 was regarded as significant. through the online survey from questionnaire stars, we finally received 165 qualified questionnaires, and the recovery rate of the questionnaire was 100%. the average age of the respondents was 34.16 ± 8.06 (years), the average length of employment was 11.35 ± 8.60 (years), the average working day on the fever clinic or isolation ward was 15.65 ± 46.63 (days), the average anxiety score was 42.79 ± 8.50, and the average depression score was 46.94 ± 11.60. tables 1 and 2 show the results. with 50 points as the critical value (both for sas and sds), nine people were considered to have anxiety symptoms, with a prevalence of 11.4% (9/79), and 36 people were considered to have depression symptoms, with a prevalence of 45.6% (36/79). there were statistical differences (p < 0.05) in the total score of negative responses and a history of anxiety or depression between the anxiety group and non -anxiety group, while there were statistical differences (p < 0.05) in gender between the depression group and non -depression group. table 3 presents the results. then, by using linear regression analysis, we found that history of depression or anxiety (t=-2.644, p= 0.010, 95%ci: -10.514~-1.481) was a risk factor for anxiety symptoms in doctors, while being male (t=2.970, p=0.004, 95%ci: 2.667~13.521) was a protective factor for depression. table 4 lists the results. with 50 points as the critical value (both for sas and sds), 24 people were considered to have anxiety symptoms, with a prevalence of 27.9% (24/86), and 37 people were considered to objects of concern heavy workload, n(%) 12 ( have depression symptoms, with a prevalence of 43.0% (37/86). there were statistical differences (p < 0.05) in the history of anxiety or depression between the anxiety group and non -anxiety group, while there were statistical differences (p < 0.05) in the total scores of active response, history of anxiety or depression, and specialty between the depression group and non -depression group. table 5 presents the results. then, by using linear regression analysis, we found that a history of depression or anxiety was a common risk factor for anxiety symptoms (t=-3.635, p=0.000, 95%ci: -16.360~-4.789) and depression symptoms (t=-2.835, p=0.005, 95%ci:-18.238~-3.254) in nurses. table 6 lists the results. the results of partial correlation analysis (controlled for gender and history of depression or anxiety) indicated that the total score of positive coping was negatively correlated with the total score of anxiety (r=-0.182, p=0.002) and depression (r=-0.253, p=0.001) in the current study, we investigated the prevalence and influencing factors of anxiety and depression symptoms in the first-line medical staff fighting against novel coronavirus pneumonia in gansu, and came to some interesting conclusions: 1) the prevalence rate of anxiety and depression symptoms among doctors was 11.4% and 45.6%, respectively; 2) the prevalence rate of anxiety and depression symptoms among nurses was 27.9% and 43.0%, respectively; 3) a history of depression or anxiety (t=-2.644, p= 0.010, 95%ci: -10.514~-1.481) was a risk factor for anxiety symptoms in doctors, while being male (t=2.970, p=0.004, 95%ci: 2.667~13.521) was a protective factor for depression; 4) a history of depression or anxiety was a common risk factor for anxiety symptoms (t=-3.635, p=0.000, 95%ci: -16.360~-4.789) and depression symptoms (t=-2.835, p=0.005, 95%ci:-18.238~-3.254) in nurses; 5) the results of partial correlation (controlled for gender and history of depression or anxiety) indicated that the total score of positive coping was negatively correlated with the total score of anxiety (r=-0.182, p=0.002) and depression (r=-0.253, p=0.001). previous studies had suggested that the mental health status of medical staff was worse than in the general population (15, 16) . for example, kerrien m et al. (17) found that 27% of junior doctors were suffering from depression, while 28.7% were suffering from anxiety. paiva ce et al. (18) found that 12.3%of doctors had depression (hads-d ≥ 11), and 19.4% had anxiety (hads-a ≥ 11). a systematic review of 29 studies showed that the prevalence of anxiety and depression among students in medical schools in europe, the uk, and elsewhere in the englishspeaking world outside of north america was 7.7-65.5% and 6.0-66.5%, respectively (19) . similarly, a cross-sectional survey showed that the prevalence of anxiety symptoms in nurses was 43.4% (20) . another cross-sectional survey indicated that the prevalence rate of anxiety among female nurses was 41.1% (21) . maharaj s et al. (22) found that the prevalence rates of depression and anxiety among australian nurses were 32.4% and 41.2%, respectively. so, our conclusions were not consistent, and this difference might come from the use of different investigation tools. interestingly, we found that the anxiety level (x 2 = 7.019. p=0.011) of nurses was significantly higher than that of doctors, but there was no difference in depression (x 2 = 0.108. p=0.756) between the two groups. so we need to pay more attention to nurses in order to relieve their anxiety. in the present study, we found that being male (t=2.970, p=0.004, 95%ci: 2.667~13.521) was a protective factor for depression in doctors. there is considerable discourse surrounding the disproportionate diagnosis of men with depression as compared to women, often times cited at a rate around 1:2 (23) . however, the view that depression rates are universally higher in women is challenged, as biological determinants, sex role changes, and social factors might also contribute to this difference (24) . what's more, meta-analyses of diagnoses and symptoms show that the gender difference peaks in adolescence but then will decline and remain stable in adulthood, and cross-national analyses also indicate that larger gender differences are found in nations with greater gender equity for major depression, but not depression symptoms (25) . but beyond that, a systematic review of nineteen studies indicates that the male gender is significantly associated with suicide in individuals with depression (26) . so, the relationship between gender and depressive symptoms needs to be verified by a large-scale longitudinal study. we also found that a history of anxiety or depression was a risk factor for anxiety symptoms in doctors, and a common risk factor for anxiety and depression symptoms in nurses. osasona so et al. (27) found that previous mental illness was significantly associated with anxiety, depression, or general psychiatric morbidity in a sample of inmates in a nigerian prison. ahmed a et al. (28) found that a history of depression and stress was associated with depressive and anxiety symptoms in a sample of 615 women in saskatchewan from pregnancy to 5 years postpartum. stafford l et al. (29) found that women with a psychiatric history and high neuroticism are at the greatest risk for future morbidity after adjusting for confounders, such as age, education, and living alone. therefore, our conclusions are consistent. by using partial correlation analysis (controlled for gender and history of depression or anxiety), we finally found that a positive coping style was a protective factor for anxiety(r=-0.182, p=0.002) and depression (r=-0.253, p=0.001), suggesting that a positive coping style was helpful in resisting negative emotions. mahmoud js et al. (30) found that reducing maladaptive coping behaviors might have the most positive impact on reducing anxiety, depression, and stress in young adult college students. wang y et al. (31) found that perceived stress had some positive effects on psychological distress, and coping style might be a mediator in this relationship among chinese physicians. in addition, holz ne et al. (32) pointed out that stress exposure would increase rates of depression and anxiety in adults, particularly in females, and had been associated with maladaptive changes in the anterior cingulate cortex (acc), while positive coping styles could help to increase the acc volume. so our conclusions were consistent. we have to admit that our research has certain limitations. first, it was just a cross-sectional study that could not establish a causal link. second, the sample size used was relatively small and therefore reduced the reliability of the study. third, we used the selfassessment scale to evaluate the depression and anxiety symptoms of the medical staff, which might have a certain result deviation. the first-line anti-epidemic medical staff have high anxiety and depression symptoms, and adopting a positive coping style will help to improve their negative emotions. the datasets analyzed in this article are not publicly available because the datasets are part of an unpublished database and the database is still being used for other manuscripts in preparation. requests to access the datasets should be directed to 156892477@qq.com. the studies involving human participants were reviewed and approved by the ethics committee of the second clinical medical college of lanzhou university. the patients/ participants provided their written informed consent to participate in this study. written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article. wl and ls contributed to the study concept and design. jz acquired the data. lz, hw, and af collected the data. sx and by analyzed the data and drafted the manuscript. all authors read and approved the final manuscript. case of the index patient who caused tertiary transmission of covid-19 infection in korea: the application of lopinavir/ritonavir for the treatment of covid-19 infected pneumonia monitored by quantitative rt-pcr suggestions for prevention of 2019 novel coronavirus infection in otolaryngology head and neck surgery medical staff. zhonghua er bi yan hou tou jing wai ke za zhi = chin j otorhinolaryngol head neck surgery stress-induced mechanisms in mental illness: a role for glucocorticoid signalling association between depression and enterovirus infection: a nationwide population-based cohort study anxiety and depression symptoms in a general population and future risk of bloodstream infection: the hunt study is there any association between toxoplasma gondii infection and depression? a rating instrument for anxiety disorders a self-rating depression scale screening for anxiety and depression: reassessing the utility of the zung scales comparison of hospital anxiety and depression scale (hads) and zung self-rating anxiety/ depression scale (sas/sds) in evaluating anxiety and depression in patients with psoriatic arthritis correlation of depression and anxiety with social support and quality of life in patients with chronic wounds zhong nan da xue xue bao yi xue ban = j cent south university core self-evaluation and burnout among nurses: the mediating role of coping styles work-family conflict and job burn-out among chinese doctors: the mediating role of coping styles application and practice of "questionnaire star" in c language flipped classroom teaching mental health and related factors of hospital nurses determinate factors of mental health status in chinese medical staff: a cross-sectional study prevalence of anxiety disorders and depression among junior doctors and their links with their work doctor, are you healthy? a cross-sectional investigation of oncologist burnout, depression, and anxiety and an investigation of their associated factors medical student depression, anxiety and distress outside north america: a systematic review anxiety symptoms among chinese nurses and the associated factors: a cross sectional study serial multiple mediation of organizational commitment and job burnout in the relationship between psychological capital and anxiety in chinese female nurses: a cross-sectional questionnaire survey prevalence and risk factors of depression, anxiety, and stress in a cohort of australian nurses an illness of power: gender and the social causes of depression gender differences in depression gender differences in depression in representative national samples: meta-analyses of diagnoses and symptoms risk factors for suicide in individuals with depression: a systematic review prevalence and correlates of depression and anxiety disorder in a sample of inmates in a nigerian prison trajectories of maternal depressive and anxiety symptoms from pregnancy to five years postpartum and their prenatal predictors anxiety and depression symptoms in the 2 years following diagnosis of breast or gynaecologic cancer: prevalence, course and determinants of outcome the relationship among young adult college students' depression, anxiety, stress, demographics, life satisfaction, and coping styles perceived stress and psychological distress among chinese physicians: the mediating role of coping style positive coping styles and perigenual acc volume: two related mechanisms for conferring resilience? key: cord-262049-c8uzehft authors: li, ruilin; chen, youlin; lv, jianlin; liu, linlin; zong, shiqin; li, hanxia; li, hong title: anxiety and related factors in frontline clinical nurses fighting covid-19 in wuhan date: 2020-07-24 journal: medicine (baltimore) doi: 10.1097/md.0000000000021413 sha: doc_id: 262049 cord_uid: c8uzehft the aim of this study was to examine the anxiety status of the frontline clinical nurses in the designated hospitals for the treatment of coronavirus disease 2019 (covid-19) in wuhan and to analyze the influencing factors, to provide data for psychologic nursing. this study used a cross-sectional survey design and convenience sampling. the questionnaires were completed by 176 frontline clinical nurses. anxiety was determined using the hamilton anxiety scale. general data were collected using a survey. correlation analyses were used. among the 176 frontline nurses, 77.3% (136/176) had anxiety. the anxiety scores of the frontline clinical nurse fighting covid-19 were 17.1 ± 8.1. anxiety symptoms, mild to moderate anxiety symptoms, and severe anxiety symptoms were found in 27.3%, 25%, and 25% of the nurses, respectively. sex, age, marital status, length of service, and clinical working time against covid-19 were associated with anxiety (p < .05). the frontline nurses working in the designated hospitals for the treatment of covid-19 in wuhan had serious anxiety. sex, age, length of service, and clinical working time against covid-19 were associated with anxiety in those nurses. psychologic care guidance, counseling, and social support should be provided to the nurses to reduce their physical and mental burden. nursing human resources in each province should be adjusted according to each province's reality. china is a vast country with complicated terrain in various provinces and cities. major natural disasters, accidents, public health and safety incidents, and diseases and epidemics occur from time to time. [1] severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is currently endemic in china, causing a large number of cases of coronavirus disease 2019 (covid-19), which can cause severe respiratory disease and death in severe cases. since december 2019, the virus has been spreading throughout the country and the entire world, and the world health organization raised a level 1 alert. as of february 2, 2020, a total of 14,423 cases were confirmed in china, of which 304 died, for a mortality rate of 2.1% in china. nowadays, person-to-person transmission and aerosol transmission are recognized as transmission ways between nurses and patients and within families. medical personnel is the core of the rescue team. [2] nurses are always present to the frontline of any public health situation or crisis, and human-to-human transmission and aerosol transmission will not only harm the frontline nursing staff but also bring great psychologic impact. at present, china has a large number of nurses engaged in the battle against covid-19. due to the sudden outbreak of sars-cov-2, the number of nurses involved in the response was very limited, and most of them did not have enough experience and preparation to deal with it. [3] disasters always cause psychologic problems of varying degrees. [4] covid-19 was not only a disaster to the chinese community but also a critical challenge for the medical staff, with its load of detrimental psychologic impacts. nevertheless, when facing a deadly situation involving a dangerous virus, large numbers of patients, and highly intensive work, psychologic problems of different degrees are bound to occur. [5] to fight the psychologic war against this "psychologic epidemic" secondary to covid-19, it must first be characterized to manage it appropriately. the first of patients with covid-19 reported exposure to a large seafood and live animal market in wuhan city, hubei province, suggesting a potential zoonotic origin. wuhan city is at the core of the battle against sars-cov-2 and is also the hardest-hit area in china. to understand the psychologic state of the first cohort of frontline nurses in the designated hospitals in wuhan city, we investigated and analyzed their anxiety and the related factors, hoping to provide data for the psychologic intervention of frontline and rescue nurses. frontline nurses in hospitals treating covid-19 in hubei province in january 2020 and february 2020 were enrolled. the nurses were from the tertiary hospitals in wuhan city, hubei province, that were designated to receive new patients with covid-19. this study was approved by the ethics committee of the guangxi university of chinese medicine. informed consent was obtained from all participants included in the study. two scales were used to collect the data. the general information questionnaire included sex, age, ethnicity, length of service, professional title, education level, marital status, and clinical working time against covid-19. the hamilton rating scale for anxiety (hama) [6] is the most commonly used clinician-rated measure of anxiety in the treatment studies of depression. [7] it consists of 14 symptom-defined elements, and covers both psychologic and somatic symptoms, comprising anxious mood, tension (including startle response, fatigability, and restlessness), fears (including of the dark, strangers, and crowds); insomnia; "intellectual" (poor memory or difficulty concentrating); depressed mood (including anhedonia); somatic symptoms (including aches and pains, stiffness, and bruxism); sensory (including tinnitus and blurred vision); cardiovascular (including tachycardia and palpitations); respiratory (chest tightness and choking); gastrointestinal (including irritable bowel syndrome-type symptoms); genitourinary (including urinary frequency and loss of libido); autonomic (including dry mouth and tension headache), and observed behavior at interview (restless, fidgety, etc). according to the data provided by the scale collaboration group in china, a total score ≥29 indicated severe anxiety, ≥21 points indicated obvious anxiety, ≥14 points indicated anxiety; ≥7 points indicated possible anxiety, and <7 points indicated no symptoms of anxiety. in this survey, a total of 176 participants completed the survey. for those participants, 176 questionnaires were collected, and all the answers were completed, for an effective recovery rate of 100%. the questionnaires were made on the network questionnaire platform "wenjuan star" and distributed on the platform "wechat." before the investigation, a wechat group was established to invite the frontline clinical nurses to join the group. the researchers explained in detail the purpose of the survey, the principle of anonymity and confidentiality in the group, required the respondents to truthfully answer according to their actual situation, forwarded the qr codes to the wechat group, and notified the respondents to fill in and submit it during their rest time. the collected data were analyzed using spss 21.0 (ibm, armonk, ny). categorical data were expressed as absolute numbers and percentages (%). continuous data were expressed as mean ± standard deviation and analyzed using the student t test, analysis of variance, and correlation analysis. statistical significance was defined as p < .05. there were 176 participants included in the study. the characteristics of the frontline clinical nurses working against covid-19 are shown in table 1 . the average anxiety score of the 176 nurses was 17.1 ± 8.1, and 77.3% of them had anxiety symptoms. to determine the factors that influenced the anxiety of the frontline clinical nurses against covid-19, univariable analyses were performed. the results showed that sex, age, length of service, and clinical working time against covid-19 were associated with anxiety (all p < .05, table 2 ). the anxiety scores table 1 the sociodemographic characteristics of the frontline clinical nurse against covid-19 (n = 176, %). in females were significantly higher than that of males (p < .05). older nurses had higher levels of anxiety than younger nurses (p < .05). married nurses had higher levels of anxiety than unmarried nurses (p < .05). the longer the clinical hours spent fighting covid-19, the higher the anxiety level (p < .05). the shorter the clinical service, the higher the anxiety level (p < .05) the pressure source of nursing work can come from the objective environment as well as from subjective perception. [8] the sars-cov-2 is a new, highly infectious coronavirus never before encountered by humans. thus, patients need long-term care by the doctors and nurses, and this will disrupt the normal life and work to a certain extent. at the same time, long-term fights, instability, and uncertainty of patients' condition, and concerns about the health status of patients have a huge impact on the physiology, psychology, and quality of life of the nurses. [9] with the outbreak of infectious public health events, most frontline nurses do not know much about the new or sudden infectious diseases and closed management, leading to fear. [10] in the present study, 136 (77.3%) frontline nurses had symptoms of anxiety, and 44 (25%) had severe anxiety, which is consistent with the 72.8% incidence of anxiety and depression symptoms of nurses in previous studies. [11] this indicates that the disaster brings serious psychologic problems to the frontline nurses, whose inner trauma is an urgent problem to be solved. the causes for the psychologic response in the frontline nurses mainly include the following aspects. 4.2.1. the supply of protective equipment is tight, and nurses are insecure and worried about infection. in the face of covid-19, the protection requirements for paramedics are very strict. various papers and textbooks plainly describe wearing level-d protective clothing against respiratory viruses, but in practice, this is not a simple task. it takes at least 5 minutes to wear it, and taking off level-d protective clothing is even more difficult than putting it on. to save the protective clothing and the time to change protecting clothing, nurses wear diapers to work, are unable to drink water, and are unable to go to the toilet. because adult diapers do not contain much, the nurses are limited to the consumption of small amounts of milk, which will aggravate the anxiety and depression of nurses. our research showed that female nurses were more anxious than male nurses. the physiologic characteristics of a female are divided into 2 aspects: physiologic and psychologic. physically, females are not as physical as men; psychologically, females' nursing personnel were slightly more resilient than males, and females are more sensitive than males. this physical discomfort exacerbated the female nurse's anxiety. our research shows that the longer the nurses work at the frontline against covid-19, the more anxiety they experience. because they did not know the virus, the source of infection, and transmission, and they lacked awareness of prevention and control in the early stages, the nurses had high levels of anxiety. despite the improving knowledge of covid-19, the psychologic pressure of the nurses was increasing. anxiety among nurses has been exacerbated by the recent discovery that covid-19 can also be transmitted through aerosols. in this information age, a large number of unverified statements are reported in the news, causing panic among the public. at first, a large number of patients rushed to the hospital, aggravating the burden of the first cohort of designated hospital nurses. in such an environment, the anxiety of the frontline nurses in wuhan hospitals, which have been exposed to patients with covid-19 for the longest time and have the largest number of patients, will be further intensified. according to a study, 100% of the nurses in the infection department of the emergency department requested to be transferred, because they were concerned about the threat of environmental safety to health. [12] the results also showed that marital status was another relevant factor. the main reason is that nurses worry about spreading the virus to their families, or that they do not have the equipment or medication to treat them. there were nurses or family members of nurses who are infected, who had no beds, no hospitalization, and no privilege. in the face of anxiety, the body can relieve stress through its own mechanism. nevertheless, the frontline nurses were in a state of overload and super-intense work, constantly under stress, and on the verge of physical and table 2 the hars scores of the frontline clinical nurses against covid-19 (n = 176). psychologic limits. the intensity and strain of the work of the medical staff in the isolation wards during the response to sars was one of the main factors for psychologic stress. [13] from the perspective of sex, women's physical ability is not as good as men's, and the excessive workload inevitably leads to women's greater anxiety than men. another factor was that the longer they spent at the frontline, the more anxious and depressed the nurses were. the frontline nurses were scheduled in the apn mode, and each shift lasts 8 hours. due to a large number of patients, unstable conditions, and rapid changes in the condition, nurses actually worked an average of 10 hours per day, and some nurses worked up to 40 hours per week. nurses are expected to work in a meticulous, long, and focused environment, which is another major contributor to anxiety, which is supported by a previous study. [14] in the face of such a huge workload and a strong source of infection, many frontline nurses were infected, some have fallen ill, suspected infected nurses were isolated, the number of nurses able to work normally was declining, and the workload was increasing. long-term overload and super-intense work make nursing staff in the state of constant stress, on the verge of physical and psychologic limits. in addition to preventing infection, mental health is crucial. only by maintaining a healthy state of mind can we put ourselves into work efficiently. in the face to the patients suddenly increasing fever and human resource gap, hospital nursing staff from other departments were deployed, the non-nursing staff was also deployed, leading to less experienced staff having to deal with covid-19, further increasing stress and psychologic pressure. our results showed that age and length of service were 2 related factors influencing the anxiety of frontline nurses. by comparing the anxiety of the frontline nurses of different working ages, it was found that the incidence of anxiety in nurses with low seniority was higher, while the incidence of anxiety in nurses with high seniority was lower, which may be related to long-term psychologic stress and clinical knowledge. the results show that most frontline nurses were young and middle-aged, mainly female, and with experience of 1 to 10 years (81.8%). they lack experience, and, in the face of such a sudden disaster, their psychologic fear, psychologic endurance will be poor. as someone once said: "they are just a group of children, changed in a suit of clothes, the appearance of scholars predecessors, healing and saving people, and death rob people!" 4.2.4. guidance of public opinion. this outbreak is significantly different from the information transmission speed of sars in 2003. in the present outbreak, the information transmission speed is faster, but the authenticity of a lot of information cannot be guaranteed, which aggravates people's suspicion and worry and easily causes fear, which further aggravates the psychologic burden of the nurses. 4.3.1 as a professional medical worker, they first need to do is acquire a correct understanding of covid-19 and avoid the rumors on the internet. it is also essential to be able to disseminate knowledge accurately and not panic in the face of the disease. to carry out authoritative interpretation and education in a timely manner, the frontline nurses can update their knowledge of covid-19 timely through professional education in 5 minutes at the time of shift change or authoritative release of wechat groups, compilation manual of data, etc, so that the frontline nurses can know clearly that what they have done is the best treatment plan to achieve consistent thinking, consistent action, confident, and orderly in their work. in this way, the anxiety caused by fear, remorse, and guilt is eliminated. 4.3.2 covid-19 knowledge training should be taken up with their jobs. they should carry out preventive interviews to discuss their inner feelings with the appropriate resources for healthcare workers to manage their stress. 4.3.3 after entering the frontline of the epidemic, scientific, rational, and clear management and division of labor should be strengthened, with clear working standards and targets. unnecessary repetitive work should be reduced, and reasonable and effective incentive strategies should be established. reasonable schedule, appropriate relaxation and rest, and adequate sleep and diet should be emphasized. good interpersonal relationships, including medical care relationship, doctor-patient relationship, the nurse-patient relationship should be established and maintained to improve medical tasks and achieve medical goals by establishing a harmonious working atmosphere. 4.3.4 in the face of an outbreak, everyone has more or less negative emotions, especially healthcare workers, directly facing the patients. when there are negative emotions, we should reasonably face and accept the emergence of these emotions, and fully accept the rationality of the emergence of these emotions. passing over and self-blame because of these emotions will eventually lead to a vicious circle of emotions and aggravation. negative emotion management should be done well, as follows. 4.3.4.1 when emotions are difficult to control and affect work status, it is recommended to leave the stressor temporarily if possible. for example, the sense of helplessness in the face of illness, in the face of criticism from patients or family members. taking time off can help calm emotions quickly and allowing a return to work. 4.3.4.2 learning the correct expression, confiding to colleagues and friends around, making daily scheduled calls and information exchange with family members, and writing down the emotions on paper and then tearing up the paper into the trash can might help emotional catharsis. crying is not a characteristic of the weak. tears can be a source of emotional catharsis and relaxation, conducive to the maintenance of mental health. in addition, patients with very severe anxiety should use this time for possible psychologic treatment. 4.3.4.3 when taking a break from work, the nurses should try not to get information about the epidemic, should avoid relevant materials and circle of friends, chat with the people around about some irrelevant topics, and pay attention to nutrition, appropriate physical exercise, and relaxation. 4.3.4.4 during work, the nurses should focus on doing a good job in each medical process, focus on helping everyone around, affirm the value of each work, and timely encourage and affirm the work of their colleagues. in particular, they should avoid feeling guilty for a small mistake or blame others for mistakes. what is most needed in emergency work is mutual help and awareness of making up for it. in some powerless occasions, the nurses should tell themselves that they are not omnipotent, that their energy is limited, that it is impossible to do all on their own to help everyone around them, and to rely on partners. 4.3.5 whenever possible, they should try to keep in touch with their family and the outside world. they should control the situation of their family and friends to alleviate the worry about family and friends. they should be aware of the outside world and reduce the feelings of isolation. 4.3.6 they should build a place in their heart that is their own and cannot be disturbed by outsiders or living things. it must be a safe environment for use and control. it can be a familiar bed, a small yard, a small room, etc. in the process of memory, we are already feeling rest and relaxation. in the process, the nurses can mentally direct themselves to suggest to themselves "i am particularly comfortable and safe in that place, and this place is bounded and relaxed," to stimulate and evoke physical sensations, and to allow the body to fully relax and rest before resuming the fight. 4.3.7 for relaxation training, they should lie flat on a bed in a comfortable position with one hand on their abdomen and the other on their chest. they should exhale slowly to feel that their lungs have enough space to breathe deeply. they should breathe in slowly through their nose until they can breathe no more, then slowly exhale through the mouth, with the thought that all the annoyance pressure is exhaled with the dirty gas. this should be repeated for 10 minutes with smooth, soothing music. in summary, 77.3% of the nurses working at the clinical frontline against covid-19 had anxiety symptoms. about 25% of the frontline nurses had severe anxiety symptoms, indicating the emotion and burden of the nurses are not optimistic. sex, work experience, and frontline care time were major influencing factors of frontline clinical nurses' emotions. these results indicate that clinical nurses should receive psychologic care guidance, counseling, and social support to improve their mental health. the research time was limited, and the number of participants was limited. therefore, there are some limitations in the investigation of the psychologic state of the frontline medical workers. knowledge of disaster relief among nursing staff: situation and countermeasures investigation on mental stress reaction of cibiliannurese in a military hospital to earthquake disasters long-term effects of disaster exposure in early life on mental health throughout population life cycle survey on psychological stress response of civilian nursing staff in military hospital to earthquake disaster the assessment of anxiety states by rating pharmacologic treatment of dimensional anxious depression: a review the study of relationship among stressor, coping style and anxiety situation of infectious disease nurse independence and cognition poststroke and its relationship to burden and quality of life of family caregivers a qualitative study on the psychological state of nurses in emergency banks for infectious diseases psychological status survey of first clinical first-line support nurses fighting against pneumonia caused by a 2019 novel coronavirus infection general hospital infection nurse request for post transfer and reasons for resignation experience of mental state and adjustment measures of sars ward nurses a survey of psychological health state of medical and nursing staffs of fever out -patient clinic in military hospitals during sars epidemic period and analysis of its related factors medicine (2020) 99:30 www.md-journal youlin chen contributed equally to this study and are co-first authors. study design: ruilin li, jianlin lv and linlin liu. data key: cord-291709-x9llke60 authors: lin, yulan; alias, haridah; luo, xiao; hu, zhijian; wong, li ping title: uncovering physical and attitudinal barriers to adherence to precautions for preventing the transmission of covid-19 and anxiety level of people in wuhan: 2 months after the lockdown date: 2020-09-22 journal: psychosomatics doi: 10.1016/j.psym.2020.09.005 sha: doc_id: 291709 cord_uid: x9llke60 background: wuhan, the epicentre of the coronavirus diseases (covid-19) outbreak, has been locked down on january 23, 2020. we aimed to investigate the barriers to the physical prevention, negative attitudes and anxiety levels. methods: a online cross-sectional survey was conducted with the people living in wuhan between march 12th and 23rd, 2020. results: of a total of 2,411 complete responses, the mean and standard deviation (sd) for the total physical prevention barriers score was 19.73 (sd ± 5.3; range 12−45) out of a possible score of 48. using a cut-off score of 44 for the state-trait inventory (stai) score, 79.9% (95%ci 78.2−81.5) of the participants reported moderate to severe anxiety during the early phase of the outbreak and 51.3% (95%ci 49.2−53.3) reported moderate to severe anxiety after the peak of covid-19 was over (during the study period). comparing anxiety levels in the early phase of the outbreak and after the peak of the outbreak, 58.5% (95%ci 56.5−60.5) recorded a decreased anxiety. females reported a higher likelihood to have decreased levels of anxiety than males (or=1.78, 95%ci 1.48−2.14). low negative attitudes score were associated with a higher decrease in anxiety (or=1.59, 95% ci 1.33−1.89). conclusions: the attitudinal barriers to prevention of transmission of covid-19 are more prominent than physical prevention barriers after the peak of covid-19. high anxiety levels even after the peak warrant serious attention. late december of 2019, an epidemic of coronavirus disease 2019 (covid-19) spread 30 rapidly from wuhan, hubei province, china(1, 2) . since then the chinese government has 31 taken unprecedented public health measures to contain the outbreak. the epicentre has been 32 under complete lockdown since january 23, 2020. in just two months after the lockdown of to prevent the novel coronavirus are yet to be available, the society at large should continue 44 to sustain preventive practices to further contain the outbreak and prevent its re-emergence. 45 in addition to physical prevention measures, addressing negative attitudes toward infection remains an important aspect of the management and control of the outbreak. the 47 coronavirus outbreak has affected scores of global populations. the highly contagious and 48 fatal cases have provoked considerable negative attitudes, such as embarrassment, 49 social stigma and discriminatory behaviour against people with covid-19 50 infection. infectious disease negative attitudes have been recognized as major barriers to 51 timely and effective health care or treatment-seeking (6, 7). in addition, it may also affect the 52 emotion and mental well-being of a person (8). therefore, efforts to combat the 53 new coronavirus should include addressing both the physical and the attitudinal barriers to 54 adherence to precautions for preventing the transmission. the covid-19 pandemic is presenting a great challenge to the mental wellness of the people 56 in china, especially in wuhan which was placed under strict lockdown(9).likewise, the 57 pandemic also causes unprecedented mental health burden in the united states(10), united outbreak revealed that more than half of the public rated the psychological impact as 61 moderate to severe (15). nevertheless, the study was conducted in 194 cities throughout 62 china, but information on the psychological well-being of people in the epicentre of the 63 outbreak is currently lacking. the escalating outbreak that lasted for nearly 2 months before 64 its peak, was deemed to have caused deep-rooted psychological distress to the public, 65 especially in the city of wuhan. now that the outbreak has ceased, it remains unclear what is 66 the extent of the consequences of the traumatic ordeals of covid-19 on the public. post-67 traumatic distress has been recognized as an important public health concern after a traumatic 68 event, as it may cause various functional impairments, including a person's work ability and 69 daily performance (16, 17) . the previous sars outbreak evidenced serious consequences of 84 we commenced a cross-sectional, web-based survey using an online questionnaire between 85 march 12th and 23rd, 2020. the inclusion criteria were that the respondents were residents of 86 wuhan who were between 18 and 70 years old. the researchers used the social network, wechat (the most popular messaging app in china), 89 to circulate the survey link to the residents of wuhan. when participants completed the 90 survey, they received a note to encourage them to disseminate the survey link to all their contacts. the participants were informed that their participation was voluntary, and consent 92 was implied through their completion of the questionnaire. the questionnaire was developed 93 in english and was then translated into chinese. local experts validated the content of the 94 questionnaire, after which it was pilot-tested. the survey consisted of three sections, which 95 assessed i) demographic background, ii) barriers to prevention measures, iii) negative attitude 96 toward covid-19, and iv) anxiety levels. negative attitudes consist of questions about feelings of fear, avoidance, keeping a secret, 107 embarrassment, and stigma associated with covid-19 (5-item). optional answers were on a 108 4-point likert scale, with the items scored as 1 (strongly disagree), 2 (disagree), 3 (agree), or 109 4 (strongly agree). the possible total negative attitudes score ranged from 4 to 20, with 110 higher scores representing higher levels of negative attitudes. the 6-item state version of the state-trait anxiety inventory (stai-6) assessing anxiety 113 levels that was used in this study was adapted from previous studies (19, 20) . the participants 114 rated the frequency of experiencing six emotional states, namely being calm, tense, upset, 115 relaxed, content, and worried, concerning the current covid-19 outbreak. the participants 116 were asked to rate their current level of anxiety (defined as anxiety levels after the peak) and 117 their anxiety level during the early phase of the outbreak (during the first week of the 118 lockdown). a 4-point scale was used (1 = not at all, 2 = somewhat, 3 = moderately, 4 = very 119 much). the scores on the three positively worded items were reverse-coded. the total 120 summed scores were prorated (multiplied by 20/6) to obtain scores that were comparable 121 with those from the full 20-item stai (giving a range from 20 to 80) (20). a cut-off score of 44 was used to indicate moderate to severe symptoms (21, 22). the differences in the level of 123 anxiety levels were calculated. participants were grouped into 1) having current anxiety 124 levels lower than during the early phase of the outbreak − which is defined as having 125 decreased anxiety levels − and 2) having current anxiety levels similar or higher than the 126 early phase of the outbreak. a total of 2,411 complete responses were received. as shown in the first and second column 150 of table 1 , slightly over half of the participants were females (55.6%) and the highest 151 educational level was university (51.3%). slightly over one one-third (37.2%) of the participants were aged 31-50 years old. distribution by income groups shows that most of the 153 participants were earning an average monthly income below cny50,000 (43.5%) and 154 between cny50,000 and 120,000 (31.9%). shown that a relatively higher proportion reported negative attitudes toward covid-19 than 161 those toward physical prevention barriers. over half reported strongly agree/agree with 162 regard to avoidance behaviour (56.2%), followed by embarrassment (39.9%) and fear 163 (38.8%). the mean and standard deviation (sd) for the total physical prevention barriers score was table 1 shows the multivariable logistic regression analysis of 170 demographic characteristics associated with having a higher score in physical prevention 171 barriers. the age group 18−30 years reported a significantly higher likelihood of having high 172 physical prevention barriers score than those aged 51−70 (or= 1.87; 95% ci (1.42 to 2.46). participants on an average annual income >cny130,000 (or=2.01; 95% ci 1.56 to 2.60) 174 and cny50,000 -120,000 (or=1.52; 95% ci 1.23 to 1.86) reported a higher likelihood of 175 having a higher physical prevention barriers score than those earning <cny50,000. among 176 all the occupation categories, industrial workers followed by housewife/retired reported the 177 highest proportion of a high physical prevention barriers score. the mean and sd for the total negative attitudes score was 11.5 (sd ± 4.1; range 5 to 20) out 179 of a possible score of 20. the median was 11.0 (iqr 9.0 to 14.0). the negative attitudescores 180 were categorized as a score of 11 to 20 or 5 to 10, based on the median split; as such, a total 181 of 1348 (55.9%; 95%ci 53.9 to 57.9) were categorized as having a score of 11 to 20 and 182 1063 (44.1%; 95% ci 42.1 to 46.1) had a score of 5 to 10. severe anxiety during the current moment. table 2 shows the prevalence of moderate to in total, 41.4% (95% ci 39.5 to 43.5) recorded current anxiety scores similar or higher than 201 the score during the early phase of the outbreak, whereas 58.5% (95% ci 56.5−60.5) 202 recorded current anxiety levels lower than during the early phase of the outbreak. table 3 203 shows the multivariate analysis of factors associated with a reduced level of anxiety. females 204 reported a higher likelihood of having decreased levels of anxiety than males (or=1.78, 205 95%ci 1.48 to 2.14). having lower negative attitudes score was associated with a higher 206 decrease in anxiety (or=1.59, 95% ci 1.33 to 1.89). the 31−50 years age group, participants 207 whose average annual income was cny50,000 to 120,000, and office workers reported the 208 highest likelihood of having a decreased anxiety level. to our knowledge, this study is the first investigation aimed preventive measures, attitudes 212 and anxiety levels of the public in wuhan, the epicentre, after the peak of covid-19, and the 213 findings could offer an insight into the strategies required to effectively address prevention 214 gaps and the provision of emergency psychological intervention. in general, the study participants have a good level of physical prevention measures even 216 though the peak of the covid-19 is declared over. a large proportion has difficulty in using 217 eye-protection, which could be due to difficulties in obtaining face shields or goggles. of of important note, the study found a relatively higher proportion expressed negative attitudes 241 toward covid-19 infection. this implies that attitudinal barriers are more prominent than 242 physical prevention barriers. a prominent negative attitude-avoidance behaviour-found in 243 this study implies the importance of encouraging the cultivation of timely and appropriate 244 health-seeking attitudes when one is suspected of having been infected with covid-19. it is 245 equally important to note that cognitive avoidance also contributes to a delay in taking 246 precautions to prevent the spread of covid-19. also noteworthy is that the second most 247 prominent negative attitudes after cognitive avoidance were embarrassment and fear of being known to have covid-19 infection, whereby both were reported by over one-third of the 249 study participants. likewise, fear and embarrassment were found to deter seeking medical 250 care in other infectious diseases such as hepatitis b infection and hiv(24, 26) . equally 251 essential to note is the findings of significant differences in negative attitudes according to 252 demographics. in contrast to physical prevention measures, the older adults in this study 253 demonstrated higher negative attitudes toward covid-19. in this study, males and 254 participants from higher income groups also tend to demonstrate higher negative attitudes 255 toward covid-19, which provides important population-level information to address socio-256 economic factors that drive attitude disparities. the finding that nearly 80% of respondents reported moderate to severe anxiety during the this perhaps implies that females are able to recuperate emotion more quickly than males. more importantly this study also found that a more positive attitude towards covid-19 279 infection is associated with a reduction in anxiety levels, which again emphasizes the study is an open survey, hence the denominator is not observable and the response rate is 301 unable to be calculated. therefore the current study may be affected by sampling 302 bias.therefore, the results should be interpreted with caution. despite these limitations, 303 the study data contribute tremendously to the understanding of public responses and anxiety 304 levels, especially now that the epidemic is growing exponentially. outbreak of pneumonia of unknown etiology in wuhan, china: 345 the mystery and the miracle the continuing 2019-ncov epidemic 347 threat of novel coronaviruses to global health -the latest international journal of infectious diseases : ijid : official publication of the 349 international society for infectious diseases china says its covid-19 peak is over tuberculosis stigma as a social 359 determinant of health: a systematic mapping review of research in low incidence countries. 360 international journal of infectious diseases : ijid : official publication of the international society for 361 infectious diseases a comparative study of the stigma 363 associated with infectious diseases (sars, aids, tb). hong kong medical journal = xianggang yi xue 364 za zhi applied innovations and 366 technologies timely mental health care for the 368 2019 novel coronavirus outbreak is urgently needed. the lancet psychiatry covid-19 and mental health equity in the united states. social psychiatry and 370 psychiatric epidemiology mental health before and during 372 the covid-19 pandemic: a longitudinal probability sample survey of the uk population. the lancet 373 psychiatry mental health services in italy during the 378 covid-19 outbreak. the lancet psychiatry challenges for mental health services 380 during the 2020 covid-19 outbreak in germany. psychiatry and clinical neurosciences associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic 384 among the general population in china. international journal of environmental research and public 385 health post-traumatic stress disorder: evidence-based 387 research for the third millennium. evidence-based complementary and alternative medicine : ecam the epidemiology of 390 trauma and post-traumatic stress disorder in a representative long-term psychiatric morbidities among sars 393 survivors. general hospital psychiatry threat to democracy: physical and 395 mental health impact of democracy movement in hong kong the development of a six-item short-form of the state scale of the 398 the british journal of clinical psychology longitudinal assessment of 401 community psychobehavioral responses during and after the 2003 outbreak of severe acute 402 respiratory syndrome in hong kong. clinical infectious diseases : an official publication of the 403 infectious diseases society of america some norms and reliability data for the state--trait 405 anxiety inventory and the zung self-rating depression scale. the british journal of clinical 406 psychology analyzing barriers for implementation of public health and social 408 measures to prevent the transmission of covid-19 disease using dematel method. diabetes & 409 metabolic syndrome clinical features of patients infected with 411 2019 novel coronavirus in wuhan communicating 413 the risk of death from novel coronavirus disease (covid-19) hiv-related stigma: 416 implications for symptoms of anxiety and depression among malawian women public mental health crisis during covid-19 pandemic, china. emerging 424 infectious diseases role and importance of consultation-liaison 426 psychiatry during the covid-19 epidemic consultation-liaison psychiatry in china. shanghai archives of psychiatry † decrease in stai score -stai score after peak < stai score early phase of outbreak key: cord-337530-qgv29qql authors: idrissi, abdelkrim janati; lamkaddem, abdelaziz; benouajjit, abdelilah; el bouaazzaoui, manar; el houari, farah; mohammed alami; labyad, sanae; chahidi, abderrahman; benjelloun, meryem; rabhi, samira; kissani, najib; zarhbouch, benaissa; ouazzani, reda; kadiri, fouzia; alouane, rachid; elbiaze, mohamed; boujraf, said; el fakir, samira; souirti, zouhayr title: sleep quality and mental health in the context of covid-19 pandemic and lockdown in morocco date: 2020-08-12 journal: sleep med doi: 10.1016/j.sleep.2020.07.045 sha: doc_id: 337530 cord_uid: qgv29qql • high prevalence of sleep disorders, anxiety, and depressive signs were found in covid-19 pandemic and lockdown. • false believes on sleep concepts were assessed. • such false believes were presenting a risk factor of sleep disorders, anxiety, and depression. • a program of sensitization should be initiated to fight against false sleep beliefs. • valuing protection procedures of health workers and all high-risk people. • offer better access to provided psychological support through dedicated setup. the covid-19 is a pandemic that affected morocco. the first case of the country was the lockdown is a hard psychological and social experience for most people; it requires physical and social distancing, including being separated from family and friends, as well as the frustration resulting from the commitment to sit at home. this new life configuration leads to significant consequences on sleep and mental health [7] . many methods were used to study the harmful effects of the lockdown, including collecting population data using the interview, electronic survey, and phone calls [8] . the literature showed increased mental health disorders such as sleep disorders, anxiety-related symptoms, depressive symptoms, post-traumatic stress, and psychological burn-out symptoms [9, 10] . covid-19 pandemic has dramatically impacted world population life compared to earlier epidemics, such as sars, h1n1, and horse flu [11, 12] . indeed covid-19 impact might be higher on healthcare workers [8, 13] . throughout this study, we aimed to study sleep disorders and psychological impact associated with the spread of the covid-19 and the lockdown on the moroccan population. we j o u r n a l p r e -p r o o f intended to correlate the respondents' beliefs and attitudes about sleep with sleep disorders, anxiety-related symptoms, and depressive symptoms in our population. we used the dbas-16 scale. a descriptive cross-sectional study was conducted from april 1, 2020, to may 1, 2020, in morocco. we collected data using a questionnaire, including seven sections. the first one contains sociodemographic information such as the age and gender of participants, their we conducted and transferred the electronic version of the questionnaire to the moroccan population. the survey was self-applied, considering the pandemic conditions requiring physical and social distancing, and lockdown. the survey was addressed to the targeted population through social media and groups. we achieved a primary pilot and feasibility investigation to assess any constraint that might occur during the survey. hereafter, we conducted a preliminary evaluation of 10 respondents to ensure the clarity of questions and fluency. the mean duration of the self-applied survey was 11.8 ±2.1 minutes. dbas-16 test consists of 16 statements that estimate the respondents' beliefs and attitudes about sleep. each statement was scored according to a scale ranging from 1 (strongly j o u r n a l p r e -p r o o f disagree) to 10 (strongly agree). we asked respondents to express and estimate their degree of agreement with each statement by choosing the number that outfits their state. the test was subdivided into four sub-scales: consequences of insomnia (statement 5, 7, 9, 12 and 16) , worry about sleep (statement 3, 4, 8, 10, 11, 14) , sleep expectation (statement 1and 2) and assignment of drug (statement 6, 13 and 15) [14] . we calculated the total score by summing the four subscales scores. finally, the totals score over/equal to 4 refers to false beliefs about sleep, whereas scores less than 4 refers to the right or accurate beliefs about sleep. ais scale aimed to assess any sleep troubles that are experienced by respondents during the covid-19 lockdown stage. ais included eight statements that assess the onset of sleep (the time it takes to sleep after turning off the light) and the wake up during the night and in the morning. ais test evaluates the full duration and quality of sleep (no matter how long they slept). besides, ais test statements allow estimating stress caused by insomnia experience and the desire to sleep during the day and their interference with routine daily activities. the respondents describe each sleep difficulty by choosing an expression that best describes their states, provided they have experienced this condition at least three times a week during the last month [15] . we calculated ais scores by summing the scores obtained for each statement. scores over or equal to 6 indicate the presence of insomnia, while scores less than 6 show the absence of insomnia. we have used the epworth sleepiness scale as a subjective measure of respondents' sleepiness. the test consists of a list of eight situations that allow evaluating the tendency to become drowsy on a scale ranging from 0 (chance of falling asleep) to 3 (a strong chance to fall asleep). to score the ess test, we add the value of respondents' answers on a scale ranging from j o u r n a l p r e -p r o o f 4 0 to 24. the scale estimates whether respondents are suffering from excessive drowsiness that might require medical consideration. the scores ranged from 0 to 10, referring to a healthy subject, the scores ranging from 11 to 15 refers to moderate daytime sleepiness, and a score between 16 and 24 reflects that respondent suffers from severe daytime sleepiness. [16] hars test measures the severity of anxiety symptoms. it consists of 14 assessments; a series of symptoms defined each one. these assertions are mixed and take into account the psychic (mental agitation and psychological distress) and somatic (physical complaints related to anxiety) aspects of anxiety. each item is scored on a scale ranging from 0, reflecting no presence of symptom to 4, reflecting the highest severity of symptoms; the total score ranges between 0 and 56. scores less than 14 are considered normal, while scores ranged between 14 and 17 is reflecting a subject with mild anxiety. also, a score ranging between 18 and 24 refers to moderate anxiety, and scores over 25 indicate severe anxiety [17] . we used the bdi test to screen depression and measure the behavioral manifestations and severity of depression. it consists of eight statements; each one contains four choices. respondents choose the suggestion that best describes their situation; if more than a single choice was suitable to describe the subject situation, they should choose the highest number for that group. choices were scored respectively 0 for the first choice, 1 for the second choice, 2 for the third choice, and 3 for the fourth choice. scores ranging from 4 to 7 do indicate mild depression, 8 to 15 are assigned to moderate depression, 16 and over are indicating severe depression [18] . the descriptive statistics approach was used to describe the demographic variables such as gender, age, localization of residence, education level, and profession. the mean age of our j o u r n a l p r e -p r o o f sample was 35 years old. hence, we considered two subgroups: a first group below the average age and a second group above the average age. the prevalence of depressive symptoms, anxiety, and sleep quality were reported. variables with p ≤ 0.20 on univariate analysis were taken into account in the multivariate logistic regression model to assess the potential factors influencing depressive symptoms, anxiety, and sleep quality during the covid-19 lockdown stage. odds ratio (or), adjusted odds ratio (aor), and 95% confidence interval (95% ci) were obtained from logistic regression models. the p-value of equal or less than 0.05 was considered significant. the statistical analysis of the data was performed using the statistical software package spss 17.0 (statistical package for the social sciences). the results revealed a high prevalence of sleep disorder, especially insomnia (56.0%) and daytime sleepiness (9.9%). also, 29.5% of respondents had anxiety. besides, the results of the beck depression inventory revealed that 35.6% of respondents suffered from depressive symptoms. table 2 summarized the results from this univariate and multivariate logistic regression. the analysis revealed that insomnia was significantly predicted by area and chronic disease, the insomnia score was higher within urban respondents (or = 2.09 (1.21-3.62); p<0.05) and people with chronic diseases (or = 2.14 (1.42-3.22); p<0.05) compared respectively with rural and respondents' without chronic disease. furthermore, gender and age constitute significant p<0.05) were more likely to develop anxiety than people without chronic disease, urban, and being male, respectively. accurate beliefs about sleep prevent respondents from insomnia (p<0.001), daytime sleepiness (p<0.001), anxiety (p<0.001), and depressive symptoms (p<0.001) ( table 3 ). the study of the association between respondents' sleep knowledge using the dbas-16 score, ais, and ess scores were performed by correlation analysis. this analysis showed that the correlation between dbas and ais yielded an r= 0.546 with p< 0.001, the correlation between dbas and ess yielded an r= 0.294 with p< 0.001, the scores were significant. ais and ess scores increase with the dbas-16 score. a correlation analysis showed that the association between ais on one hand and anxiety (r= 0.670; p< 0.001) and depressive symptoms (r= 0.516; p< 0.001), on the other hand, was significant. these associations were positive; the increase of the ais score leads to an increase of depressive symptoms and anxiety scores. the correlation analysis shows that the relationship between ess on one hand and anxiety (r= 0.325; p< 0.001) and depressive symptoms (r= 0.209; p< 0.001), on the other hand, was significant, the increase of ess score leads to increased scores of anxiety and depressive symptoms. we conducted this study to evaluate the weight of covid-19 infection lockdown on the sleep and psychological state of the moroccan population and to find the causes underlying the recent studies showed that adverse psychological effects had been reported during the lockdown period of the covid-19 outbreak [8, 9] ; these psychological effects included post-traumatic stress symptoms, confusion, anger, and psychological burn-out symptoms. our study disclosed a high prevalence of sleep disorder, especially insomnia (56.0%) and daytime sleepiness severe (9.9%). additionally, 17.1% of the studied sample has developed severe anxiety, moderate anxiety (12.4%). the results of the beck depression inventory revealed that 35.6% of respondents suffered from depressive symptoms (mild depression: 21.5%, moderate depression: 12.4%, and severe depression: 1.6%). before the covid-19 pandemic and lockdown, the prevalence of sleep disorders, anxiety, and depression in morocco was 18.6%, 4.5%, and 4.5%, respectively [19, 20, 21] . it seems that during this period of the lockdown, the prevalence of sleep disturbances has increased. in china, the overall prevalence of anxiety disorders, depressive symptoms, and sleep quality of the public during the lockdown period were 35.1%, 20.1%, and 18.2%, respectively [22] . the increase of such disorders was associated with several stressors. during the outbreak, there was a high risk of infection, a longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, and inadequate information, financial j o u r n a l p r e -p r o o f loss, stigma overwork, frustration, discrimination, isolation, patients with negative emotions, a lack of contact with their families, and the excess information from mass media [8, 13, 22, 23] . additionally, there was a strong correlation between the prevalence of sleep disorder, anxiety, and depressive symptoms. our results confirmed that insomnia and daytime sleepiness were predicted by anxiety and depressive symptoms. sleep disorders were associated with anxiety [24] . a close relationship between the occurrence of sleep disorders and anxiety disorders in the general population has been demonstrated [25] [26] [27] [28] . furthermore, sleep deficiency during stress states increases exposure to anxiety [29] . in humans, acute and chronic stress has been shown to have harmful effects on sleep that are released through activation of the sympathetic system [30] . the association between sleep problems and depressive symptoms had been reported in low and middle-income countries [31] . besides, this study confirmed that the coexistence of sleep problems and depressive symptoms increased the risk for the expansion of anxiety and stress among these populations [31] . people with chronic diseases were more likely to develop insomnia and anxiety. sleep disorders are pervasive in people with cancer and chronic medical conditions [32] [33] [34] [35] [36] . furthermore, respondents from the urban area with chronic diseases were more likely to experience anxiety-related symptoms than those from rural areas and those without chronic diseases. also, the anxiety symptoms were more frequent within women compared to men. people living in an urban area would spend much time to follow covid-19 news. moreover, covid-19 cases were more frequent in urban areas and cities compared to rural areas. almost 20% of the respondents developed symptoms of depression of type mild to moderate, while 1.6% of our sample expressed a severe depression. furthermore, women and respondents, aged less than 35 years old, were more exposed to depressive symptoms than men and people aged 35 years or older. recent covid-19 related research showed that age less than < 35 years-old and time spent focusing on the covid-19 news along 3 hours or more per day were associated with a generalized anxiety disorder. however, the prevalence of women's j o u r n a l p r e -p r o o f depressive symptoms and anxiety-related symptoms was different from other research that demonstrated that women and men were similarly affected [12] . we recommend fighting against false sleep beliefs, and we must provide adequate psychiatric and psychological support to those people suffering from insomnia, anxiety and depression related to fear and anxiety developed in an environment of covid-19 outbreak. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. the authors declared no conflict of interest. the icmje uniform disclosure form for potential conflicts of interest associated with this article can be viewed by clicking on the following link: we do like to thank all participants for the survey we conducted that allowed us to originate the results reported in this paper. j o u r n a l p r e -p r o o f the consequences of the covid-19 pandemic on mental health and implications for clinical practice european psychiatry. the journal of the association of the psychological impact of quarantine and how to reduce it: a rapid review of the evidence public responses to the novel 2019 coronavirus (2019-ncov) in japan: mental health consequences and target populations survey of insomnia and related social psychological factors among medical staff involved in the 2019 novel coronavirus disease outbreak. front. psychiatry the immediate psychological and occupational impact of the 2003 sars outbreak in a teaching hospital generalized anxiety disorder, depressive symptoms, and sleep quality during the covid-19 outbreak in china: a web-based cross-sectional survey impact on mental health and perceptions of psychological care among medical and nursing staff in wuhan during the 2019 novel coronavirus disease outbreak: a cross-sectional study. brain, behavior, and immunity 2020 dysfunctional beliefs and attitudes about sleep (dbas): validation of a brief version (dbas-16) athens insomnia scale: validation of an instrument based on icd-10 criteria a new method for measuring daytime sleepiness: the epworth sleepiness scale the assessment of anxiety states by rating an inventory for measuring depression prevalence of anxiety disorders: a population-based epidemiological study in the metropolitan area of casablanca global prevalence of anxiety disorders: a systematic review and meta-regression the association between sleep problems and psychotic symptoms in the general population: a global perspective the mental health consequences of covid-19 and physical distancing factors associated with mental health outcomes among health care workers exposed to coronavirus disease is there an association between short sleep duration and adolescent anxiety disorders? epidemiological study of sleep disturbances and psychiatric disorders: an opportunity for prevention? sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults place of chronic insomnia in the course of depressive and anxiety disorders sleep and anxiety disorders insomnia symptoms and short sleep predict anxiety and worry in response to stress exposure: a prospective cohort study of medical interns interactions between stress and sleep: from basic research to clinical situations sleep problems and depression among 237 023 community-dwelling adults in 46 low-and middle-income countries impact of breast cancer treatments on sleep disturbances-a systematic review prevalence, putative mechanisms, and current management of sleep problems during chemotherapy for cancer the development and impact of insomnia on cancer survivors: a qualitative analysis prostate cancer treatments and their side effects are associated with increased insomnia sleep disorders and sleep quality in moroccan adult patients with cancer during treatment key: cord-349219-tl97bj42 authors: rayhan arusha, anowara; kishore biswas, raaj title: prevalence of stress, anxiety and depression due to examination in bangladeshi youths: a pilot study date: 2020-07-18 journal: child youth serv rev doi: 10.1016/j.childyouth.2020.105254 sha: doc_id: 349219 cord_uid: tl97bj42 an estimated 25% people suffer from mental health disorders worldwide. almost 7 million suffer from anxiety and depression in bangladesh. there are several factors that can cause stress among youths, both academic and non-academic, ranging from socioeconomic, environmental, cultural and psychological attributes. however, these are not widely researched in bangladesh. this study identified the factors that affect the mental health of students due to examinations in bangladesh, particularly the socio-demographic, lifestyle and psychological factors. an online cross-sectional survey was conducted on may 2020 with a sample size of 210 tertiary level students in dhaka. a modified dass-21 was used to measure stress, anxiety and depression scores related to examination. binary logistic model showed that those who lived with family, spent time with parents, had regular sufficient (self-assessed) sleeps and consumed balanced (self-assessed) diets had significantly lower stress, anxiety, and depression. balanced lifestyle with greater social bonding might help to better equip youths to reduce stress, anxiety, and depression during examination, which could be an avenue for future intervention studies. one in four people suffer from mental or neurological disorders worldwide (world health organisation, 2001) , including 264 million who suffer from depression (world health organization, 2020a) . a person with depression often functions poorly at work, school or in family environment, which, at its worst, can lead to suicide. due to depression, suicide is the second leading cause of death for 15-29 year-olds (world health organization, 2020a). the global prevalence of moderate to extreme levels of depression is 60.8%, anxiety 73%, and stress 62.4% (bayram and bilgel 2008; beiter et al. 2015; kulsoom and afsar 2015) . although not widely discussed, mental health issues are increasingly becoming a threat to low-and middle-income countries such as bangladesh. almost 7 million people in bangladesh experience depressive and anxiety disorders respectively (world health organization, 2020b ). an estimate of 10,167 committed suicide in 2012, and suicide attempts were considered by 4% of boys and 6% of girls by youths aged 13-17 years (world health organization, 2020b) . in bangladesh, the levels of depression, anxiety, and stress has been reported to be as high as 54.3%, 64.8%, and 59.0%, respectively (hossain et al., 2014; alim et al., 2017; saeed et al., 2018; mamun and griffiths, 2019; mamun et al., 2019) . there are myriads of factors that can cause stress among students, both academic and non-academic, ranging from socioeconomic, environmental, cultural to psychological attributes (brand and schoonheim-klein, 2009 ). stress levels vary across students depending on symptoms of anxiety, especially during examination periods. a prevalence rate of 10-35% of university students experience "functionally impairing levels of test anxiety" (chapell et al., 2005; neuderth, jabs and schmidtke, 2009) . students with test anxiety are more likely to delay and drop-out in university, which could lead to suicidal behaviors and high economic costs (schaefer et al. 2007) . it can be bidirectional as majority of students with stress display poor self-confidence and often poor academic performance (sohail, 2013; baste and gadkari, 2014) . several contributing factors of stress, anxiety, and depression among students were identified in literature including sex, strained relationships, family and peer pressure, high parental expectation, lack of financial support and hardships, sleep deprivation, future worries, loneliness, longer screen time, toxic psychological environment, academic pressure, workload, size of the academic curriculum, and heavy test schedules (brenneisen mayer et al., 2016; abdel wahed and hassan, 2017; saeed et al., 2018; silva and figueiredo-braga, 2018; ul haq et al., 2018; mamun and griffiths, 2019) . some of the major academic stressors for students include examinations, time demands, competition and class environment while the most common personal stressors have been intimate relationships, finance and parental conflicts (murphy and archer, 1996) . the stress of examinations and mental health of students are correlated. according to bayram and bilgel (2008) , exam stress and anxiety has negative impacts on students' academic achievement, physical health & development and standard of life. causes of exam anxiety can be associated with social stigma, where students from a rural background could feel incompetent compared to those who grew up in the metropolitan, coupled with the fear of not having competitive skills in english, the general medium for higher education in bangladesh, can demotivate them prior to and during exams which could lead to anxiety, stress, and frustration. higher education in recent times involves considerable financial burden (callender & kemp, 2000) . roberts et al.'s (1999) cross-sectional survey indicate that financial difficulties often lead to mental disorders such as depression for students. roberts et al.'s (1999) cross-sectional survey indicate that financial difficulties make students particularly vulnerable to depression. of all the adverse experiences assessed, financial hardship was the only one to show an independent relationship with depression when pre-entry anxiety and depression were controlled which indicates that the direction of causality is more likely to be from financial problems to depression than vice versa (andrews and wilding, 2004) . moreover, excessive parental control is assumed to inhibit the development of children's autonomy, which leads to perceptions of the environment as "uncontrollable and a limited sense of personal competence or mastery" (chorpita, albano and barlow, 1996; hudson and rapee, 2001; dadds, 2002; barlow, 2004; chorpita, brown and barlow, 2016) . in turn, these factors are postulated to contribute to the triggering anxiety in children. there is a knowledge gap concerning mental health problems in bangladesh. in 2019, four suicides and one suicide rescued among students attracted media and public attention nationwide, which suggested a need to examine the existing mental health issues among students in bangladesh (shamsuddin et al., 2013; arafat and al mamun, 2019) . to contribute to that gap, the present study investigated the prevalence of depression, anxiety, and stress among bangladeshi students and their associated risk factors with respect to socio-demographics and lifestyle measures. the objective of the study was to identify factors that affect the mental health of students due to examinations, particularly the socio-demographic and psychological factors using a survey conducted in dhaka, bangladesh in 2020. there are several theories that discuss risk factors associated with individual mental health. these include the social ecologic theory, the social cognitive theory, as well as the social stress model, among others (van praag et al., 2009; yen, michael and perdue, 2009 ). the present study was framed by the social ecologic theory and the social cognitive theory. the social ecologic theory suggests that individual and environment factors are interrelated and that good health can be achieved with behavioral, economic, and social factors promoting it (krieger, 1994; cohen, scribner and farley, 2000) . thus, the social ecologic theory suggested that a person living in a neighborhood with low socioeconomic status (ses) and low social support is expected to have worse health outcomes than someone from a better environment. the theory posits that environmental factors, socio-demographic factors in the current study context, influence the mental health of students. the most common socio-demographic factors discussed in the literature are the student's age, sex, place of residence, education, parents' education, family income, personal income, relationship status, frequency of contact with family and extra-curricular activities. social cognitive theory links these socio-demographic factors with the thought processes of students that contribute to their emotional, behavioral and psychological development such as seeking help, reading books, engaging in volunteering activities, getting sufficient sleep, maintaining a balanced diet, getting regular exercise and practicing relaxation techniques.. the theory also suggests that good health is linked to individuals having beliefs that they can achieve healthy outcomes, having goals to achieve these outcomes as well as having expectations of these outcomes. (bandura, 2004; fisher et al., 2004) . [ figure 1 . theoretical hypothesis for the study based on social ecologic and social cognitive theories.] an online survey was conducted among undergraduate and postgraduate students from tertiary institutions of dhaka, bangladesh. due to the covid-19 pandemic in bangladesh, the authors had to settle for online option and could only collect quantitative data. a total of 210 youths aged between 17 to 25 years participated in the survey using google online survey platform after receiving ethical clearance from university of dhaka, bangladesh. the data was collected during may 2020. the survey questionnaire included sociodemographic information as well as dass 21 scale which measured examination stress, anxiety and depression, and possible coping mechanisms. demographic information included sex, residence before joining university, current living status, relationship status, and contact with parents. the depression, anxiety and stress scale -21 items (dass-21) is a set of scales designed to measure the psychological states of depression, anxiety and stress. there are 7 items in each of the three dass-21 scales, divided into subscales with similar content. the depression scale assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest/involvement, anhedonia and inertia (lovibond and lovibond, 1995) . the anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect during examination. it examines the difficulty to relax, nervous arousal, and being easily upset/agitated, irritable/over-reactive and impatient (lovibond and lovibond, 1995) . scores for the three emotional states of mind are calculated by summing the scores for the relevant items. the stress/anxiety coping mechanism included questions regarding whether the participant ever sought help for depression/anxiety/stress, reading habits, engagement in volunteering activities, whether the participant made any effort to replace negative thoughts with positive ones, and self-assessment on quality of sleep and eating habits. bivariate distribution of the relevant variables across dass stress, dass anxiety and dass depression were quantified. the primary associations were evaluated using t-tests or analysis of variance (anova). to assess the relationships between the dass scores and socio-demographic variables, linear regression model was fitted. these models included only the variables that were found significant in the primary bivariate associations. p-value < 0.05 was considered as threshold for the level of significance. all statistical analysis was conducted with r (version 3.5.0). the online survey resulted to 210 responses. in the sample 169 were studying in undergraduate degrees, 40 in master's degrees and one in high school and aged between 17 and 25 years. the validity of the three dass scores were assessed using cronbach's alpha. the alpha values for stress, anxiety and depression were 0.84 (95% ci: 0.81 ~ 0.84), 0.80 (95% ci: 0.76 ~ 0.84) and 0.88 (95% ci: 0.85 ~ 0.90) respectively. these show that the scores were reliable. and balanced diet were fitted to linear regression model. the linear regression models observed a significant association of contact with parents with stress and depression (table 2) . those who kept contact with parents only once or twice a month were more likely to have higher examination stress and depression respectively compared to those who contacted daily with their parents. similarly, sleeping pattern was significantly (p < 0.05) associated with stress and depression during examinations. those who had sufficient sleep were less likely to have higher stress or depression compared to those who self-reported of insufficient sleep. only diet was associated with anxiety (table 2) . those who had balanced diet were likely to have lower anxiety during examination period compared to those with unbalanced diet. also, anxiety was marginally associated (p < 0.058) with living status, that is those living without family were more likely to experience anxiety than those living with it. for all the linear regression model, generalized varianceinflation factors (gvif) were computed and all scores were under 2, which means there were no multicollinearity in the models (fox and monette, 1992) the results showed that living with family, time spent with parents, sleeping patterns and diets were significantly associated with mental health factors. given the current study evaluated students who only had mild or moderate stress, anxiety or depression, it could be argued that a balanced lifestyle with sound social communication would help students deal with stress, anxiety and depression related to examination. talking with parents daily seemed to be a stress relieving mechanism among youths, as results indicate. students who talked to their parents daily over phone had the lower stress and depression scores resulting from examinations compared to those who talked 1-2 times a month. a pilot study of children with separation anxiety disorder (choate et al., 2005) found that a parent-child intervention designed to improve the attachment bond resulted in children no longer fitting criteria for separation anxiety disorder in most cases. that would work for examination stress as well, given, a student who shares the concerns are more likely to receive support and encouraging behaviors from their parents. social bonding has proved to be a good depression coping mechanism (karriker-jaffe, foshee and ennett, 2011). thus, improving the parent-youth attachment, particularly for academic examination related mental health issues, could be an avenue to alleviate excess anxiety and depression. students who generally had sufficient sleep regularly had lower examination related stress and depression compared to those who never had sufficient sleep. recent epidemiological studies suggest that insomnia is not just a typical symptom of depression, rather it could be an independent risk factor for depression in the long run (hohagen et al., 1993) . although this study did not evaluate a bidirectional relationship, depression is considered to be one of the most frequent and prominent causes of insomnia (hohagen et al., 1993) . however, academic performance might not necessarily be hindered due to insomnia (taylor, d.j., bramoweth, a.d., grieser, e.a., tatum, j.i. and roane, 2013) but lack of adequate sleep was found to be associated with a range of impairments in terms of academic functioning (hysing, m., pallesen, s., stormark, k.m., lundervold, a.j. and sivertsen, 2013) . a disruptive sleeping pattern or lack of it during examination period would suggest higher likelihood of stress, which would result in a deterioration in academic performance. many young adults face traumatic experiences and mental illnesses during university period. higher consumption of food due to anxiety is common. more often, anxiety leads to unbalanced diet and overconsumption of processed food, which hampers the bodily functions (kemp, bui, and grier 2013; weng et al. 2012) . in one study, m. hossain, naher, and shahabuddin 2005, found that participants who had healthy food habit had the lowest scores of anxiety, stress and depression respectively whereas students who did not have healthy food habit had the highest scores. food habit is also affiliated with students who live without family, more often they rely on campus canteens or substandard dormitory cafes. this could lead to less than adequate nutrient intake, particularly when studies have repeatedly questioned nutrition in food sources in bangladesh (hossain, naher and shahabuddin, 2005; khan et al., 2019) . all these are compounded by factors such as financial condition, sufficient resources and facilities which play a major role here. higher levels of examination anxiety were observed for students who lived without their family compared to those who lived with their family. results indicated that youths with higher anxiety level perceived their mothers and fathers as being more socially isolating, more concerned about others' opinions, more ashamed of the students' shyness and poor performance, and less socially active than youths with low anxiety level (caster et al., 1999) . staying with family reduces their stress, anxiety and depression, particularly during examination, as they could share some responsibilities with their families and focus more on academic workload. this, in turn, relieves some anxiety and improves their mental health. there were a few limitations to this study. first, there was no active identification of severely stressed individuals to be included in the survey, which might have observed stronger effect sizes in the models. second, this study was limited to only quantitative data, which means future studies could consider in-depth interviews to explore more focused examination related stress factors. also, as the sample size was small, the beta scores in the regression model might not be adjusted to reflect population estimates. thirdly, as the data was cross-sectional, there is hardly a scope to assess a causal link. based on the study findings, some intervention studies can explore the causal link between healthy lifestyle and mental health related factors during examination in bangladesh. moreover, future studies can consider calculating quality-adjusted life year (qaly) & disability-adjusted life year (daly) and assess their impacts. fourthly, the financial barrier between public universities and private institutions in bangladesh could act as a stressor, which was not collected in the current survey. finally, the sample was limited to only youths pursuing higher education in dhaka, bangladesh. for more generalized conclusion, wide scale surveys with funding would be necessary. examinations have a negative effect on the mental health of students in terms of stress, anxiety, and depression. this study explored some demographic factors associated with mental health for bangladeshi tertiary level students. balanced lifestyle with greater social bonding might help better equip fighting stress, anxiety, and depression during examination. future research could examine the relationship between academic results and its association with stresses and psychological disorders. amidst the high density of infections and non-communicable diseases, mental health is still not highly reorganized in bangladesh. implementation of stress management workshops, improvisation of academic environment, use of problem-focused and emotion focused strategies at the policy level should be targeted. moreover, students need assistance and co-curricular programming to help them develop "stress-related coping strategies" attuned to performance and the outcomes borne regarding the effects of stress, in particular regarding eustress, where a positive impact has been cited with respect to the effects of stress on financial aid, institutional commitment, academic performance, and intent to persist. prevalence and associated factors of stress, anxiety and depression among medical fayoum university students translation of dass 21 into bangla and validation among medical students the relation of depression and anxiety to life-stress and achievement in students repeated suicides in the university of dhaka 31; 143 health educ behav at univ of rochester library on anxiety and its disorders: the nature and treatment of anxiety and panic source: pubmed 298 baste and gadkari indian the prevalence and socio-demographic correlations of depression, anxiety and stress among a group of university students the prevalence and correlates of depression, anxiety, and stress in a sample of college students is the osce more stressful? examination anxiety and its consequences in different assessment methods in dental education factors associated to depression and anxiety in medical students: a multicenter study relationship between youth and parent perceptions of family environment and social anxiety test anxiety and academic performance in undergraduate and graduate students parent-child interaction therapy for treatment of separation anxiety disorder in young children: a pilot study cognitive processing in children: relation to anxiety and family influences perceived control as a mediator of family environment in etiological models of childhood anxiety -republished article a structural model of health behavior: a pragmatic approach to explain and influence health behaviors at the population level', preventive medicine learning and intimacy in the families of anxious children', in the effects of parental dysfunction on children neighborhood-level influences on physical activity among older adults: a multilevel analysis generalized collinearity diagnostics prevalence and treatment of insomnia in general practice -a longitudinal study', european archives of psychiatry and clinical neuroscience mental disorders in bangladesh: a systematic review food security and nutrition in bangladesh: progress and determinants parent-child interactions and anxiety disorders: an observational study sleep patterns and insomnia among adolescents: a population-based study examining how neighborhood disadvantage influences trajectories of adolescent violence: a look at social bonding and psychological distress when food is more than nutrition: understanding emotional eating and overconsumption factors associated with the availability of iodized salt at household level: a case study in bangladesh epidemiology and the web of causation: has anyone seen the spider? stress, anxiety, and depression among medical students in a multiethnic setting the structure of negative emotional states: comparison of the depression anxiety stress scales (dass) with the beck depression and anxiety inventories prevalence and psychiatric risk factors of excessive internet use among northern bangladeshi job-seeking graduate students: a pilot study the association between facebook addiction and depression: a pilot survey study among bangladeshi students stressors on the college campus: a comparison of 1985 and 1993 the association between muslim religiosity and young adult college students' depression, anxiety, and stress assessment of depression, anxiety, and stress among medical students enrolled in a medical college strategies for reducing test anxiety and optimizing exam preparation in german university students: a prevention-oriented pilot project of the university of wã¼rzburg mental health in a gendered context: gendered community effect on depression and problem drinking', health and place determinants of anxiety and depression among university students of lahore mental health and performance of medical students with high and low test anxiety correlates of depression, anxiety and stress among malaysian university students evaluation of the relationships among happiness, stress, anxiety, and depression in pharmacy students stress and academic performance among medical students epidemiology of insomnia in college students: relationship with mental health, quality of life, and substance use difficulties psychometric study of depression, anxiety and stress among university students is there any relationship between dietary patterns and depression and anxiety in chinese adolescents? mental disorders affect one in four people, world health organization world health organization (2020a) depression, world health organization world health organization (2020b) mental health: current mental health situation in bangladesh neighborhood environment in studies of health of older adults. a systematic review key: cord-308300-p9jyyt08 authors: taylor, steven title: anxiety disorders, climate change, and the challenges ahead: introduction to the special issue date: 2020-09-22 journal: j anxiety disord doi: 10.1016/j.janxdis.2020.102313 sha: doc_id: 308300 cord_uid: p9jyyt08 climate change involves (1) increases in the prevalence of extreme weather events (e.g., wildfires, floods, hurricanes), (2) more gradual climatic changes (e.g., rising sea levels, desertification), and (3) increased risks of pandemics and other widespread disease outbreaks. anxiety evoked by the threat of climate change can be either adaptive or maladaptive. adaptive anxiety can motivate climate activism, such as efforts to reduce one’s carbon footprint. maladaptive anxiety can take the form of anxious passivity, where the person feels anxious but incapable of addressing the problem of climate change, and may take the form of an anxiety disorder triggered or exacerbated by climatic stressors. such stressors may involve exposure to extreme weather events or may involve exposure to other stressors such as forced migration due to rising sea levels or desertification. three types of interventions are needed to address the various types of climate-related anxiety: (1) programs that motivate people to overcome anxious passivity and thereby take action to mitigate the effects of climate change, (2) treatment programs that address anxiety associated with exposure to climatic stressors, and (3) programs that build resilience at an individual and community level, to help people better cope with the challenges ahead. at no point in human history have we faced such an array of both familiar and unfamiliar risks, interacting in a hyperconnected, rapidly changing world. new risks and correlations are emerging. decades-old projections about climate change have come true much sooner than expected. with that come changes in the intensity and frequency of hazards. risk really is systemic, and requires concerted and urgent effort to reduce it in integrated and innovative ways. (united nations office for disaster risk reduction, 2019, p. iii) the anthropocene, which is our current geological epoch, is a period during which human activity is the dominant influence on climate and the environment. the anthropocene is an epoch that will be filled with climate-related existential threats. the goal of the special issue for the stressors such as rising sea levels can also lead to the loss or damage to places of cultural importance such as places of worship. people who are strongly attached to their possessions, homes, or areas of residence may find it especially difficult to evacuate during extreme weather events. in the case of wildfires, this can result in injury or death when people refuse to evacuate (conaway, 2016) . climate change-related forced migration will become a growing problem in the coming years, as coastal towns are flooded and other regions become uninhabitable due to heat and desertification (robinson, dilkina, & moreno-cruz, 2020) . clayton (2020) observed that stressors can be directly experienced or encountered vicariously through news or social media. research by gibson et al. (2020) in this special issue illustrates the distinction between direct and indirect impacts. in studying the effects of climate change on the pacific island nation of tuvalu, gibson et al. observed that the residents were anxious about both the direct, local environmental impacts of climate change on their island nation, and also by news reports about global climate change and its future threats. clayton (2020) further observed that climate-related anxiety may be an appropriate reaction to a realistic threat, or it may be excessive and disproportionate. the distinction is important. appropriate levels of anxiety can serve as a motivator, providing an impetus for people to take action to address climate threats, such as by finding ways of reducing their carbon footprint. unfortunately, however, as noted by hrabok et al. (2020) in this special issue, some people experiencing appropriate levels of anxiety may lapse into helplessness and despair if they believe that their personal or collective acts are insufficient to deal with the challenge of climate change. excessive anxiety-that is, anxiety that is highly disproportionate given the level of threatcan be severe and debilitating, meriting clinical attention. hrabok et al. (2020) , in this special issue, described in detail the psychological impacts of extreme environmental events, which include posttraumatic stress disorder (ptsd), anxiety disorders, mood disorders, substance-used disorders, and other clinical problems. high levels of anxiety and other disorders are likely to occur for victims of forced migration (jannesari, hatch, & oram, 2020) . the psychological impact of climate change is likely to be complex and varied, as people try to cope with a mix of acute and chronic stressors. anxiety is one of a range of responses to climate change, in addition to depression, grief, and anger. denial of the threat of climate change is another psychological reaction to this existential threat. little is known about whether clinically significant climate-related anxiety is always part of some dsm-5 disorder or where it could form some other kind of syndrome. research into covid-19-related anxiety revealed evidence of a covid stress syndrome, not readily characterized by dsm-5, consisting of worries about personal health, worry about the socioeconomic impact of the pandemic, xenophobia, traumatic stress symptoms (e.g., nightmares and intrusive thoughts about covid-19), and covid-19-related compulsive checking and reassurance-seeking . something similar could be true of climate-related anxiety; it may be part of a broader syndrome of worry, checking, and intrusive thoughts, rather than neatly fitting into an existing dsm-5 diagnostic category. further research is needed to investigate this issue. several of the contributors to this special issue describe how climate-related stressors have a greater impact on some demographic groups than others. clayton (2020) observed that j o u r n a l p r e -p r o o f younger people, compared to older adults, tend to report greater climate-related anxiety, most likely because younger people, unlike older adults, will be most likely to live through the climatic adversities in the decades to come. climate-related anxiety also tends to be greater in people who deeply care for the environment (clayton, 2020) . levels of climate anxiety are likely to increase over time as increasingly more people are directly impacted. people in poverty, indigenous peoples, children, and people living in precarious circumstances (e.g., in areas prone to droughts or wildfires, or regions vulnerable to rising sea levels) are among the at-risk groups for experiencing severe effects of climate change (clayton, 2020; hrabok et al., 2020; gibson et al., 2020) . living in communities where there is a lack of social support or a lack of other stress buffers is also likely to be a risk factor for anxiety-related pathology when climate-related stressors such as floods occur. people with pre-existing mental health problems, such as pre-existing anxiety disorders, may be strongly affected by the stressors of climate change. although this remains to be fully investigated, research suggests that the stressors associated with pandemics (which may be climate-related), can worsen emotional problems for people with pre-existing anxiety or mood disorders . climate change entails many uncertainties, such as uncertainties about whether one's home will be destroyed in a wildfire, or uncertainties about one's safety and livelihood in cases of forced migration. accordingly, people who have a great deal of difficulty tolerating uncertainty will find climate change to be particularly stressful. the intolerance of uncertainty is a personality trait that is a vulnerability factor for a variety of types of anxiety-related pathology (rosser, 2019) . other personality traits that might provide to be vulnerability factors for climate-related anxiety are likely to be many of the same traits that are vulnerability factors for pandemic-related anxiety. these include negative emotionality (neuroticism), the tendency to overestimate threat, and anxiety sensitivity (fear of arousalrelated sensations) (taylor, 2019) . people with high scores on these traits may be at particular risk for developing anxiety disorders as a result of climate-related stressors. the various types of vulnerabilities to climate-related anxiety can be cumulative in their effects, and so it is essential to develop and refine interventions to protect at-risk groups. future pandemics are inevitable (taylor, 2019) . while there is no evidence that the covid-19 pandemic was climate-related (wyns, 2020) , climate change and pandemics are linked in many ways. climate change facilitates the spreading of many kinds of infectious disease; for example, outbreaks of tropical diseases in temperate climates. this can occur, for example, when regions become warmer and wetter, thereby providing suitable habitats for disease vectors such as mosquitos and birds. it has been predicted that the outbreaks of numerous kinds of disease may become more prevalent as a result of climate change, including influenza, dengue, cholera, and malaria (chowdhury, nur, hassan, von seidlein, & dunachie, 2017; curseu, popa, sirbu, & stoian, 2010; hertig, 2019; watts et al., 2019) . some outbreaks have the potential of becoming the next pandemic. extreme weather events such as wildfires and hurricanes typically require people to evacuate their homes and relocate to shelters. during a pandemic, this makes it difficult to implement social distancing, meaning that some people may refuse to evacuate (thereby increasing the risk of trauma or death), while other people may choose to relocate to shelters (thereby increasing the risk of infection). this was a concern during the recent wildfires and j o u r n a l p r e -p r o o f hurricanes in the united states, which occurred during the covid-19 pandemic (salas, shultz, & solomon, 2020; shultz et al., 2020) . extreme heat poses additional challenges to covid-19 mitigation efforts. for example, wearing a face mask is uncomfortable in high heat and humidity and may exacerbate risks for heat-related illnesses; conversely, not wearing a mask increases the likelihood of spreading covid-19 (salas et al., 2020) . extreme weather events such as wildfires can increase air pollution. this can exacerbate respiratory diseases. indeed, during covid-19, exposure to air pollution appears to have increased mortality in patients infected with sarscov2 (wu, nethery, sabath, braun, & dominici, 2020) . in summary, the co-occurrence of pandemics or other disease outbreaks during climaterelated stressors, such as extreme weather events, will seriously compound the stressors that people may experience, thereby increasing the risk for anxiety disorders and related clinical conditions such as ptsd. coping with combined extreme weather events (e.g., wildfires, hurricanes) and pandemics will involve (1) improved communication about dual need to evacuate and to engage in socially distancing, (2) improved evacuation shelters that make possible both social distancing and hygiene precautions, and (3) learning from each storm to refine operations . timely action, forethought, and trust in science are key to dealing with climate emergencies (manzanedo & manning, 2020) . this means mitigating realistic anxiety by scientifically-based climate activism rather than denying, dismissing, or discounting the threat of climate change. one of the challenges is to find ways of countering anxious passivity and defeatism, in which people are distressed about climate change but feel helpless about their ability to do anything about it, which can lead them to deny, dismiss, or trivialize the climate problem as a means of coping with climate anxiety. several of the articles in this special issue touch on this important topic. for example, mah et al. (2020) offer recommendations about how to structure communication to the public in order to promote adaptive coping with climate change and to minimize the odds that people will dismiss fear-evoking messages about the threat of climate change. this involves tailoring the message to both the type of climate stressors and the type of recipients of the messages (e.g., the recipient's coping style). in an indirect way, the covid-19 pandemic may provide people with incentives to take action against climate change. during this pandemic, in which large numbers of people were in self-isolating "lockdown", there were notable reductions in air pollution, at least temporarily (tollefson, 2020) . these effects were rapid and dramatic, and provide a clear example of how we can have a positive impact on the environment by reducing our carbon footprint. this provides an example of how we can learn from the covid-19 pandemic in order to cope with the challenges of climate change. communities should be reminded of these effects in order to motivate people of taking action to reduce their carbon emissions. this may be a potent antidote to anxious passivity and defeatist attitudes. chen et al. (2020) , in this special issue, remind us that most people are resilient in response to climate disasters and that enduring levels of distress have been observed only in a minority of people. nevertheless, even if 10-15% of people developed severe anxiety or other disorders, as estimated from research on various kinds of natural disasters (e.g., galatzer-levy, huang, & bonanno, 2018) , that could overwhelm the healthcare system. understanding the process of adaptation, as reviewed by chen et al., may eventually lead to important new insights about how to strengthen resilience at both an individual and population level. mah and colleagues (2020) delineated the different types of resilience that are needed to cope with adverse climatic events, including resilience at the levels of the individual and community levels. mah et al. propose that resilience arises from a combination of adaptive emotion-focused and problem-focused coping. at an individual level, adaptive coping with climate change stress involves helping people to manage their emotional responses, deal with practical immediate problems, and prepare to mitigate future hazards. various types of programs have been developed to improve a person's hardiness or resilience to stress. for climate-related stressors, these may be important in reducing the risk of anxiety disorders and related clinical conditions such as ptsd. such programs can be made available to people who don't have psychological disorders but may be at risk for such disorders, such as having environmental, occupational, or psychological risk factors. regarding occupational risk factors, there are encouraging but preliminary studies that stress-management and related programs that can improve the resilience among firstresponders (wild, el-salahi, & esposti, 2020) . there are encouraging findings that the risk of developing anxiety disorders can be reduced by targeting psychological risk factors such as the person's level of anxiety sensitivity (e.g., knapp et al., 2020) . however, the efficacy of such programs in reducing the risk of anxiety disorders has yet to be firmly established. several other anxiety prevention programs have been developed, for either children or adults, in various formats including face-to-face and internet-based interventions. these cognitive-behavioral programs might be useful in building resilience in people who are at risk of exposure to climate-related environmental stressors. unfortunately, however, the results so far have been disappointing. such prevention studies have been evaluated in several recent metaanalyses and found to have weak or small effects in reducing the risk of anxiety or mood disorders (caldwell et al., 2019; deady et al., 2017; moreno-peral et al., 2017) . clearly, much work needs to be done to improve anxiety prevention programs, although from a public health perspective even small effects can be of some value in improving the lives of people. community resilience refers to the ability of communities to cope with external stressors, and is influenced by social capital (e.g., social networks), infrastructure, and vulnerabilities (mah et al., 2020) . strong community resilience involves cooperation, altruism, strong leadership, solid social networks, and the necessary resources. building community resiliency may entail partnerships between health authorities and schools and community organizations to reduce mental health stigma and facilitate the accessibility and delivery of mental health services (newnham, titov, & mcevoy, 2020) . the covid-19 pandemic, along with previous pandemics, has shown that communities can rapidly come together to support one another (barzilay et al., 2020; taylor, 2019) , although the persistence of such altruism may wane over time. to cope with climate change, we need to find ways to develop enduring altruism and other forms of social support within communities, in order to buffer the effects of the stressors associated with climate change. as noted by hrabok et al. (2020) , multiple strategies will be necessary for communities to prepare for and cope with climate-related stressors, including enhanced access to medical and psychological services, inter-agency cooperation, and ensuring that practical resources are available in the event of disasters (e.g., shelters, food, clean drinking water). the covid-19 pandemic should serve as a wake-up call for governments, communities, and individuals to ensure that healthcare systems are better prepared to meet the challenges of the future, many of which will be climate-related. pandemics, just like climate change disasters, are mass events requiring large-scale psychological interventions. we will need to re-think the way in which mental health services, such as the treatment of anxiety and traumatic stress disorders, are delivered in the future. the luxury of a one-to-one consultation may become a thing of the past as the need for large-scale interventions become necessary. covid-19 has forced practitioners to move to online formats, and researchers and service providers have begun developing and implementing online platforms for providing mental health advice and services on a large scale. those platforms should not be dismantled once the covid-19 pandemic has passed, because they will be vital for addressing climate-related mental health problems in the years ahead. challenges in implementing such platforms for climate-related catastrophes need to be carefully considered. access to personal computers may not be feasible during climate disasters, but hopefully, people will have access to their cellular phones, which may prove to be an important way of connecting to mental health services and resources. regardless of the availability of digital resources, screen-and-treat approaches, implemented on a mass scale, will be important for identifying and triaging people with clinically significant psychological problems, such as climate-related anxiety disorders or other clinical conditions such as ptsd, so that they can receive empirically supported interventions. disclosure: the author declares no conflicts of interest. j o u r n a l p r e -p r o o f do pre-existing anxiety-related and mood disorders differentially impact covid-19 stress responses and coping resilience, covid-19-related stress, anxiety and depression during the pandemic in a large population enriched for healthcare providers school-based interventions to prevent anxiety and depression in children and young people: a systematic review and network meta-analysis anxiety and resilience in the face of natural disasters associated with climate change pandemics, pathogenicity and changing molecular epidemiology of cholera in the era of global warming climate anxiety: psychological responses to climate change waiting for fire potential impact of climate change on pandemic influenza risk ehealth interventions for the prevention of depression and anxiety in the general population: a systematic review and meta-analysis trajectories of resilience and dysfunction following potential trauma: a review and statistical evaluation the mental health impacts of climate change: findings from a pacific island atoll nation distribution of anopheles vectors and potential malaria transmission stability in europe and the mediterranean area under future climate change threats to mental health and well-being associated with climate change seeking sanctuary: rethinking asylum and mental health test of an anxiety sensitivity amelioration program for at-risk youth (asapy) coping with climate change: three insights for research, intervention, and communication to promote adaptive coping to climate change covid-19: lessons for the climate change emergency effectiveness of psychological and/or educational interventions in the prevention of anxiety: a systematic review, metaanalysis, and meta-regression preparing mental health systems for climate crisis investigating the increase in domestic violence post disaster: an australian case study modeling migration patterns in the usa under sea level rise intolerance of uncertainty as a transdiagnostic mechanism of psychological difficulties: a systematic review of evidence pertaining to causality and temporal precedence the climate crisis and covid-19 -a major threat to the pandemic response heat wave and the risk of intimate partner violence cascading risks of covid-19 resurgence during an active 2020 atlantic hurricane season the psychology of pandemics: preparing for the next global outbreak of infectious disease covid stress syndrome: concept, structure, and correlates. depression and anxiety how the coronavirus pandemic slashed carbon emissions -in five graphs global assessment report on disaster risk reduction the 2019 report of the lancet countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate the effectiveness of interventions aimed at improving well-being and resilience to stress in first responders: a systematic review exposure to air pollution and covid-19 mortality in the united states: a nationwide cross-sectional study. medrxiv climate change and infectious diseases weather effects on social movements: evidence from key: cord-291526-aau0hnwx authors: ge, fenfen; zhang, di; wu, lianhai; mu, hongwei title: predicting psychological state among chinese undergraduate students in the covid-19 epidemic: a longitudinal study using a machine learning date: 2020-09-17 journal: neuropsychiatr dis treat doi: 10.2147/ndt.s262004 sha: doc_id: 291526 cord_uid: aau0hnwx background: the outbreak of the 2019 novel coronavirus disease (covid-19) not only caused physical abnormalities, but also caused psychological distress, especially for undergraduate students who are facing the pressure of academic study and work. we aimed to explore the prevalence rate of probable anxiety and probable insomnia and to find the risk factors among a longitudinal study of undergraduate students using the approach of machine learning. methods: the baseline data (t1) were collected from freshmen who underwent psychological evaluation at two months after entering the university. at t2 stage (february 10th to 13th, 2020), we used a convenience cluster sampling to assess psychological state (probable anxiety was assessed by general anxiety disorder-7 and probable insomnia was assessed by insomnia severity index-7) based on a web survey. we integrated information attained at t1 stage to predict probable anxiety and probable insomnia at t2 stage using a machine learning algorithm (xgboost). results: finally, we included 2009 students (response rate: 80.36%). the prevalence rate of probable anxiety and probable insomnia was 12.49% and 16.87%, respectively. the xgboost algorithm predicted 1954 out of 2009 students (translated into 97.3% accuracy) and 1932 out of 2009 students (translated into 96.2% accuracy) who suffered anxiety and insomnia symptoms, respectively. the most relevant variables in predicting probable anxiety included romantic relationship, suicidal ideation, sleep symptoms, and a history of anxiety symptoms. the most relevant variables in predicting probable insomnia included aggression, psychotic experiences, suicidal ideation, and romantic relationship. conclusion: risks for probable anxiety and probable insomnia among undergraduate students can be identified at an individual level by baseline data. thus, timely psychological intervention for anxiety and insomnia symptoms among undergraduate students is needed considering the above factors. the 2019 novel coronavirus disease is caused by a variety of coronavirus (sars-cov-2). in march 2020, the world health organization (who) declared covid-19 as a global pandemic. 1 the symptoms of covid-19 are usually nonspecific (eg, fever, cough, and dyspnea). 2 up to now, covid-19 is significantly contagious and no effective treatments or vaccines are available. 3 as of 19 june 2020 (10:00 am cet), over 8.45 million cases have been diagnosed globally with more than 453,000 fatalities. 4 many unprecedented strategies have been taken to cut off the spread of the virus in many countries (eg, china, england, and the united states). for example, the chinese government released some guidance for the general population to self-isolate. specifically, lockdown (eg, in wuhan), temporary closure of schools/factories, and restriction of individuals' activities isolation and quarantine measures have been effective at preventing the spread of covid-19. however, consensus has arisen about their potential mental health. 5, 6 in the severe acute respiratory syndrome epidemic, confirmed cases suffered higher stress levels, poor sleep quality, and depressed mood. 7 recently, brooks' review suggested that the mental health impact of quarantine is wide-ranging and substantial. 5 in the present epidemic of covid-19, higher anxiety level (23.04%) was reported among medical staff. 8 and zhang's study found that more than onethird of medical staff suffered insomnia symptoms. 9 in addition to special groups (eg, medical staff and confirmed cases), wang's study found that about 33.33% of the general population reported moderate-to-severe anxiety. 10 isolated people may experience stressful conditions (eg, social activities and face to face communication were restricted). 11 thus, negative emotions experienced by people may be compounded. 11, 12 undergraduate education is a special stage that is highly specialized, knowledgeable, and continuous. theory teaching and practical teaching are two profiles as well as two taches in the same teaching life-cycle. the epidemic prevented undergraduate students from returning to university. thus, undergraduate students' psychological state may fluctuate. 13, 14 we found that previous studies have some limitations. firstly, most research focuses on the mental health of medical students, and ignores the mental health of students of other disciplines (eg, humanities, engineering, and agricultural). although medical students are a special group, they only constitute a very small part of undergraduate students. secondly, most of the studies have a cross-sectional design, only exploring the psychological state and risk factors of undergraduate students during the covid-19 epidemic. in summary, we aimed to investigate the prevalence rate of probable anxiety and probable insomnia and to confirm the risk factors among undergraduate students during the covid-19 outbreak. finally, we ranked risk factors in the model based on "feature importance." we have obtained the ethics committee of the ocean university of china (2,020,001). an online version of an informed consent form is provided to students before starting the survey. in the form, we explained to the students that participation was voluntary, and refusals would have no negative consequences. we also guaranteed data confidentiality and that only the researchers could access the information. undergraduate students can choose to participate in or reject the survey. if they choose to participate in the survey, they are evaluated via an online platform. if they refuse to take part in the survey, they withdraw from the online platform. we have obtained informed consent from students who accomplished the survey. the target population of the research was undergraduate students at the ocean university of china. the ocean university of china is a government university located in shandong province. the baseline survey (t1) was collected from freshmen. specifically, all freshmen underwent psychological evaluation at two months after entering the ocean university of china. in the presence of the covid-19 epidemic (t2, february 10th to 13th, 2020), we used convenience cluster sampling and invited undergraduate students (n=2500) from four grades (freshman, sophomore, junior and senior) to participate in the survey. finally, 2009 participants completed the webbased survey (response rate: 80.36%). we used the students' id numbers to match the data. basic demographic information was collected at t1 stage. we collected basic characteristics using a self-constructed questionnaire. the questionnaire included gender (female=1, male=2), year of education (first=1, second=2, third=3, fourth=4), family economic (low family economic=1, high family economic=2), upbringing place (metropolitan=1, medium and small cities=2, town=3, country=4) and singlechild families (yes=1, no=2). the ministry of education of the people's republic of china recommended the college students mental health screening scale (csmhss) as a reliable and valid measurement tool to evaluate the mental health of undergraduate students. the scale of csmhss consists of 22 dimensions. specifically, it includes psychotic experiences (4 items), suicidal ideation (3 items), the history of anxiety symptoms (4 items), the history of depression symptoms (5 items), paranoia (4 items), inferiority (5 items), sensitivity (4 items), social phobia (4 items), somatization (4 items), dependence (4 items), aggression (4 items), impulsive (4 items), obsession and compulsion (4 items), internet addiction (5 items), self-injury (4 items), eating problems (4 items), sleeping problem (4 items), school adjustment difficulties (4 items), interpersonal distress (4 items), academic pressure (4 items), employment pressure (4 items) and romantic relationship problems (4 items). the scale uses 4-point likert-scaled items ranging from 1 (not at all like me) to 4 (very like me). the scores in each dimension are added then standardized. the standard score of the total score in each dimension can be categorized at a cutoff of 3 (fang, yuan, hu, deng, and lin, 2018). the scale of general anxiety disorder (gad-7) was used in this research. it was a tool to assess anxiety symptoms. a score ≥7 indicated clinically significant anxiety symptoms. 15,16 gad-7 was well validated and sensitive to the general population. [17] [18] [19] [20] studies had shown that gad-7 has good reliability and validity in china. 21, 22 the cronbach's alpha value was 0.90 for gad-7 in this research. we used the insomnia severity index (isi-7) which is a 7item instrument that evaluates subjective sleep symptoms. each item is scored on a 5-point scale, with higher scores representing more severe insomnia symptoms. a score >14 indicates clinically significant insomnia symptoms. 23 the cronbach's alpha value was 0.86 for isi-7 in this research. descriptive data analysis was implemented in spss 21.0 for windows. xgboost (extreme gradient boosting), which is a machine learning algorithm, was implemented in python 3.70. xgboost is a method for regression and classification problems according to the gradient boosting decision tree. this method has been widely used in all kinds of data fields for regression and classification. 24 the algorithm of xgboost can utilize a cross-validation approach to divide data into a model "training set" and "testing set." in the current research, we used a 5-fold cross-validation method. classification performance was scored with the area under the receiver-operation curve (auc), sensitivity (sen), specificity (spe), and accuracy (acc). finally, there were 2009 undergraduate students who were included in our research. of the 2009 participants, 50.97% were female, 79.99% were from high family economic background, and 25.35% were from metropolitan areas. in the present epidemic of covid-19, the prevalence rate of probable anxiety and probable insomnia symptoms was 12.49% (gad-7≥7) and 16.87% (isi-7>14), respectively. the detailed basic characteristics are shown in table 1 . we integrated the data collected at t1 stage to predict probable anxiety and probable insomnia during the covid-19 epidemic (at t2 stage). the auc of probable anxiety and probable insomnia is 99.00% and 98.00%, respectively. figure 1 shows the aucs for probable anxiety and probable insomnia. according to the aucs and the confusion matrix, we calculated the sensitivity (sen), specificity (spe), and accuracy (acc). the machine learning of xgboost predicted 1954 out of 2009 as either anxiety or no-anxiety and this translated into 97.3% accuracy (97.3% sensitivity and 96.3% specificity). the machine learning of xgboost predicted 1932 out of 2009 as either insomnia or no-insomnia and this translated into 96.2% accuracy (95.5% sensitivity and 100.0% specificity). detailed information is demonstrated in table 2 . feature importance assigned positive coefficients via xgboost, indicating that an increase in probable anxiety included 1) romantic relationship problems, 2) suicidal ideation, 3) the history of anxiety symptoms, and 4) sleep symptoms. it was also indicated that an increase in probable insomnia included 1) aggression, 2) psychotic experiences, 3) suicide ideation, and 4) romantic relationship problems. the confusion matrix and "feature importance" are shown in figures 2a and b and 3a and b, respectively. in the current research, the prevalence rate of probable anxiety and probable insomnia among undergraduate students was 12.49% and 16.87%, respectively. the prevalence rate of probable anxiety is higher than the zhang's study (7.5%) and lower than the cao's study. cao's study found that 24.9% of medical students suffered from anxiety symptoms. 25 the variability of prevalence rates could be explained by medical students being a special group who face more academic and employment pressure. and previous studies found that medical students are more likely to have psychological problems. 26, 27 the prevalence rate of probable insomnia is the similarity to huang's study (18.2%) 28 and lower than the 36.1% reported by zhang's study. 9 this variability of prevalence rates could be explained by the participants, questionnaires, and regions. most relevant variables predicting probable anxiety included romantic relationship problems, suicidal ideation, history of anxiety symptoms, and sleep symptoms. falling in love is a universal behavior among undergraduate students. studies indicate that youths experience romantic relationships of joy and happiness. however, a romantic relationship is not entirely a happy period of life. bajoghli's study found that for youths, falling in love may be also associated with anxiety symptoms. 29 consistent with asselmann's study, we found that the history of anxiety symptoms prior to/at baseline predicted a recurrence of probable anxiety at the time of follow-up. 30 narmandakh's study found that sleep disturbance may precede anxiety symptoms. and anxiety symptoms might be prevented by alleviating sleep disturbance. 31 previous results suggested that the presence of "any anxiety disorder" increases the risk for suicidal ideation among the general population, even after controlling for confounding factors (wilcox et al, 2010 ). in the current study, we found that suicidal ideation can be used to predict probable anxiety. the results may indicate that there is a bidirectional relationship between suicidal ideation and anxiety symptoms among youths. most relevant variables predicting probable insomnia included aggression, psychotic experiences, suicidal ideation, and romantic relationship problems. consistent with previous studies, we also found that insomnia is a consequence of psychotic symptoms. 32 recent studies demonstrate that insomnia also contributed to the development of psychotic symptoms. 33 insomnia symptoms may be one of the top warning signs of suicide in a clinical outpatient setting. 34 suh's study also found that insomnia symptoms were related to concurrent and future ideations of suicide in a population-based longitudinal study. 35 and a meta-analysis showed that sleep disturbances in general, as well as insomnia individually, appear to represent a risk factor for suicidal ideation and behavior. 36 namely, there may be a bidirectional association of insomnia symptoms with psychotic experiences and insomnia symptoms with suicide ideation. falling in love is an emotional occurrence at any age, but for undergraduate students, the feelings might be overwhelming. 37 in addition to being a positive feeling (eg, joy and happiness), a romantic relationship may cause stress and negative effect, especially if the feeling is not reciprocal. 38 kuula's study revealed that romantic relationship is one reason for sleep disturbance in girls and may be associated with symptoms of anxiety in both boys and girls. 39 we have found relatively reliable and accurate predictive models during the covid-19 epidemic. and our models provide useful information about the most relevant variables to predict dovepress probable anxiety and insomnia among college students. the stage of university education is an important period of life development, and it is very necessary to carry out psychological assessment of freshmen who have just entered the university. intervening with students with psychological problems in a timely and effective manner would not only help them recover their mental health, but also help them adjust their state when facing emergencies. stoessel's study found besides being positive feelings, romantic relationships may cause stress and negative effect, especially if the love is not reciprocal. 38 thus, in addition to resolving regular psychological problems, it is necessary to help college students to establish healthy romantic relationships, one of the principal developmental tasks of emerging adulthood. how to effectively organize the mental health services for those undergraduates who have present anxiety and/or insomnia symptoms due to the covid-19 pandemic is also very important. community-based and school-based mental health services care be combined into the national health system. 40 there are some strengths in this research, including 1) this is a longitudinal study and we use the data at the time of enrollment to predict college students' anxiety and insomnia during the outbreak; 2) we integrate data from multiple dimensions; 3) we calculate models for individual classification using machine learning. however, the current research has some limitations, including 1) our participants are from a specific university located in shandong province. and this university does not include medical students. thus, the results cannot be generalized to all chinese undergraduates. 2) we used self-reported questionnaires in this research, so response bias and recall bias may exist considering that undergraduate students may have underreported or overreported their anxiety and/or sleep symptoms. we took some steps to reduce this by keeping uniformity of data collection approach. it is worth mentioning that we found that romantic relationship trouble is an important factor in predicting anxiety and insomnia. 3) we used different questionnaires at t1 stage and t2 stage. thus, it is difficult to directly compare the prevalence rate of anxiety and insomnia at two stages. 4) temperament is stable across the lifespan and mediate adaptive functioning to some extent. and the attachment system may be activated in stressful situations. recently, moccia's research found that some specific affective temperament (eg, cyclothymic and anxious temperaments) and attachment features (eg, need for approval) can be used to predict the burden of mental health. 41 however, information on temperamental and attachment was not collected in our study. thus, it is necessary for researchers to consider temperament and attachment in future studies. this longitudinal research contributes to our understanding of the psychological state of undergraduate students who suffered a sudden public health event. and we found a reliable model to predict anxiety and insomnia during the sudden public health. thus, timely psychological intervention is necessary, not only to help undergraduate students recover their mental health but also to help them face some emergency events. fenfen ge and di zhang are co-first authors. the authors report no conflicts of interest in this work. neuropsychiatric disease and treatment is an international, peerreviewed journal of clinical therapeutics and pharmacology focusing on concise rapid reporting of clinical or pre-clinical studies on a range of neuropsychiatric and neurological disorders. this journal is indexed on pubmed central, the 'psycinfo' database and cas, and is the official journal of the international neuropsychiatric association (ina). the manuscript management system is completely online and includes a very quick and fair peer-review system, which is all easy to use. visit http://www.dovepress.com/testimonials.php to read real quotes from published authors. china coronavirus: who declares international emergency as death toll exceeds 200 a novel coronavirus outbreak of global health concern we signed up for this!" -student and trainee responses to the covid-19 pandemic covid-19): what you need to do the psychological impact of quarantine and how to reduce it: rapid review of the evidence the consequences of the covid-19 pandemic on mental health and implications for clinical practice factors associated with psychosis among patients with severe acute respiratory syndrome: a case-control study survey of insomnia and related social psychological factors among medical staff involved in the 2019 novel coronavirus disease outbreak immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china recommended psychological crisis intervention response to the 2019 novel coronavirus pneumonia outbreak in china: a model of west china hospital psychosocial effects of an ebola outbreak at individual, community and international levels prevalence of depression and its associated factors among clinical-year medical students in eastern province, saudi arabia medical student mobilization during a crisis: lessons from a covid-19 medical student response team patient-reported outcome measures in community mental health teams: pragmatic evaluation of phq-9 a brief measure for assessing generalized anxiety disorder -the gad-7 depressive symptomatology among norwegian adolescent boys and girls: the patient health questionnaire-9 (phq-9) psychometric properties and correlates psychometric properties of the 7-item generalized anxiety disorder scale (gad-7) in a large representative sample of finnish adolescents screening for depression in primary care: a rasch analysis of the phq-9 anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection reliability and validity of the chinese version of the patient health questionnaire (phq-9) in the general population reliability and validity of chinese version of the generalized anxiety disorder 7-item (gad-7) scale in screening anxiety disorders in outpatients from traditional chinese internal department empirical validation of the insomnia severity index in cancer patients xgboost: a scalable tree boosting system the psychological impact of the covid-19 epidemic on college students in china stress and depression among medical students: a cross-sectional study systematic review of depression, anxiety, and other indicators of psychological distress among u.s. and canadian medical students mental health burden for the public affected by the covid-19 outbreak in china: who will be the high-risk group? i love you more than i can stand!" -romantic love, symptoms of depression and anxiety, and sleep complaints are related among young adults the bidirectional association between sleep problems and anxiety symptoms in adolescents: a trails report the role of sleep dysfunction in the occurrence of delusions and hallucinations: a systematic review insomnia, negative affect, and psychotic experiences: modelling pathways over time in a clinical observational study suicidality and sleep disturbances longitudinal course of depression scores with and without insomnia in non-depressed individuals: a 6-year follow-up longitudinal study in a korean cohort meta-analysis of sleep disturbance and suicidal thoughts and behaviors adolescent romantic relationships differences and similarities on neuronal activities of people being happily and unhappily in love: a functional magnetic resonance imaging study emotions relating to romantic love-further disruptors of adolescent sleep mental health during and after the covid-19 emergency in italy affective temperament, attachment style, and the psychological impact of the covid-19 outbreak: an early report on the italian general population key: cord-351057-xrv3k1fo authors: alenazi, thamer h.; bindhim, nasser f.; alenazi, meteb h.; tamim, hani; almagrabi, reem s.; aljohani, sameera m.; h basyouni, mada; almubark, rasha a.; althumiri, nora a.; alqahtani, saleh a. title: prevalence and predictors of anxiety among healthcare workers in saudi arabia during the covid-19 pandemic date: 2020-10-05 journal: j infect public health doi: 10.1016/j.jiph.2020.09.001 sha: doc_id: 351057 cord_uid: xrv3k1fo background: during pandemics, healthcare workers (hcws) may be prone to higher levels of anxiety than those of the general population. this study aimed to explore the anxiety levels among hcws in saudi arabia during the covid-19 pandemic and the predictors of increased anxiety levels. method: hcw participants in this cross-section study were solicited by email from the database of registered practitioners of the saudi commission for health specialties between 15 may and 18 may 2020. sociodemographic characteristics, work-related factors, and organization-related factors were collected. results: four thousand nine hundred and twenty hcws (3.4%) responded. reported levels of anxiety were low anxiety (31.5%; n = 1552), medium (36.1%; n = 1778), and high (32.3%; n = 1590). participants reporting high anxiety levels were more likely to be unmarried (or = 1.32, 95% ci: 1.14–1.52); nurses (or = 1.54, 95% 1.24–1.91); workers in radiology (or = 1.52, 95% ci: 1.01–2.28); or respiratory therapists (or = 2.28, 95% ci: 1.14–4.54). social factors associated with high anxiety levels were: living with a person who is elderly (p = 0.01), has a chronic disease (p < 0.0001), has immune deficiency (p < 0.0001), or has a respiratory disease (p-value <0.0001). organization-related factors associated with a high level of anxiety were: working in an organization that hosts covid-19 patients and working with such patients (p-value <0.0001). conclusion: self-reported medium and high levels of anxiety were present in 68.5% of hcws in the covid-19 pandemic. this highlights the urgent need to identify high-risk individuals to offer psychological support and provide up to date information on the pandemic. these data should help policymakers drive initiatives forward to protect and prepare hcws psychological wellbeing. the epidemic of a novel coronavirus disease 2019 (covid19) began in mainland china in late 2019 and spread throughout the world to cause a global pandemic [1] . as of august 23, 2020, there were over 23 million confirmed cases and 800,000 deaths worldwide, and the pandemic had reached 220 countries and territories [2] . in saudi arabia, as of august 27, 2020, there were 311,855 confirmed covid-19 case, with 3785 deaths [3] . emerging infectious disease pandemics usually are accompanied by a hidden silent pandemic, namely, the psychological impact [4] [5] [6] [7] . the general population, including healthcare workers (hcws), are prone to this silent pandemic. hcws, as the frontline force to control pandemics, are expected to have different levels of anxiety than those of the general population. various factors may contribute to the perceived altered anxiety levels among hcws, such as the fear of contracting the infection during work; fear of transmitting the infection to loved ones; scarcity of available knowledge; quality of the knowledge presented in the official portals or the social media; and shortage of personal protective equipment. the psychological effect of epidemics on hcws was studied during and after the severe acute respiratory syndrome (sars) epidemic in 2002. the short-term impact of the epidemic was described among chinese hcws, where 68% of those surveyed experienced high levels of stress, and 57% suffered from psychological distress [5] . moreover, hcws who had dealt with sars patients in their institutions surveyed 13-26 months after the epidemic, had higher rates of psychological distress and post-traumatic stress disorders than did hcws who were not exposed to sars patients [8] . it is not surprising that anxiety has been found associated with the current covid-19 pandemic. in a nationwide survey conducted early in the pandemic in china, almost 35% of general-population respondents reported psychological distress [9] . a month later, when the epidemic had spread to many countries outside china, a survey of 1210 respondents from the general public in 194 cities in china found that 53.8% of respondents rated the psychological impact of the outbreak as moderate to severe; 16.5% reported moderate to severe depressive symptoms; 28.8% reported moderate to severe anxiety symptoms; 8.1% reported moderate to severe stress levels [10] . in a review of 14 studies of the psychological burden of covid-19 pandemic on medical and non-medical hospital staff, significant stress and anxiety symptoms were reported by the surveyed staff [11] . in one of those studies, where 2299 hospital staff were surveyed, 22.6% reported mild to moderate anxiety symptoms, and 2.9% reported severe symptoms [12] the covid-19 pandemic is so far the largest in the current century, and none of the practicing hcws in the world had faced a pandemic of such magnitude; thus, exploration of the psychological effect of covic-19 among the hcws would be especially interesting. our study aimed to explore the prevalence of anxiety and the main predictors for high anxiety levels among hcws in saudi arabia during the current covid-19 pandemic. design this was a nation-level cross-sectional study of participants from all the 13 administrative regions in saudi arabia. participants eligible to participate in this study were healthcare professionals performing their medical duties during the peak time of covid-19 in saudi arabia. registered hcws of the saudi commission for health specialties were invited to participate via email, and the responses were collected anonymously. the study was approved by sharikhealth institutional review board (irb) number 01−2020. the study used a convenience sampling technique and a selfreported online questionnaire. assuming that there would be moderate differences between regions in terms of anxiety and sources of information, a sample of at least 80 participants per region, was required to provide a medium-effect size of 0.35 and 80% power at 95% confidence. which gives a total sample size of at least 1040 participants [13] . participants from the database of registered practitioners at the saudi commission for health specialties were invited to participate between 15 may and 18 may 2020. in the first section, after providing online consent, participants were asked about their sociodemographic characteristics, age, gender, region, and healthcare profession. questions also consisted of the type of facility, if the facility was in terms of receiving covid-19 infected patients cases or not, and if the hcw was performing all their usual. in addition to the eligibility question of being currently preforming their healthcare duties in a healthcare facility. in the second section, the participants were asked about their level of satisfaction about sufficiency and the quality of information they received about covid-19 from the healthcare institute. in the third section, participants were asked whether they worried about contracting covid-19 and spreading it to others, the frequency and severity of worrying, and general anxiety. the worry questions were adapted from the dispositional cancer worry scale, which has a total score range between 1 to 28 [14] ; using the scale, we classified the participant into three groups: low anxiety (score < 10), medium anxiety (score 10−15), and high anxiety (score > 15). the one-item question likert scale for anxiety was used to measure general anxiety [15] . in the last section, the participants were asked about the preparedness of their work facility in preventive and precautionary measures. the survey was developed by the initial group of authors using q-platform which was developed by sharikhealth, and linguistic validation was conducted by a focus group with 8 participants. the survey tool then was modified and piloted with 150 healthcare practitioners. the authors discussed the results of the pilot study, and minor modifications were made to improve the survey questions. data were transferred to the statistical package for social sciences (spss), version 25, which was used for data management and analyses. categorical variables were presented as number and percent, whereas continuous variables were presented as mean and standard deviation. a chi-square test was used to assess the association between anxiety level and various categorical variables, and the anova test was used for the continuous variables. to identify significant predictors of anxiety, we carried out multivariate (mainly multinomial regression) analyses. results were presented the survey was delivered to 143,187 registered hcws via email through the saudi commission for health specialties. our sample of 4920 hcws was collected in four days (response rate of 3.4%.) when divided into three groups according to anxiety level on the worry scale, 1552 (31.5%), 1778 (36.1%), and 1590 (32.3%) participants were in the low, medium, and high anxiety groups, respectively. personal and sociodemographic information gathered in the first part of the survey and its relation to anxiety levels described in section three is presented in table 1 . participants reporting high anxiety levels were more likely to be unmarried (or = 1.32, 95% ci: 1.14-1.52). additionally, a high anxiety level was associated with smoking, having chronic diseases, and having <5 years of experience, compared to those who reported "medicine" as their professional field, high anxiety level was associated with "nursing" (or = 1.54, 95% 1.24-1.91), "radiology" (or = 1.52, 95% ci: 1.01-2.28), and "respiratory therapy" (or = 2.28, 95% ci: 1.14-4.54), whereas anxiety level was not significantly associated with any of the other professional specializations. no significant difference in anxiety level was reported among participants from the 13 administrative regions of saudi arabia. furthermore, hcws who reported being anxious before the current pandemic, or who had been prescribed medications to relieve anxiety before the pandemic, were more likely to be more worried during the current covid-19 pandemic than were hcws who had not reported a history of anxiety. similarly, participants who reported a high level of anxiety were more likely to have sought help from a mental health professional or were considering seeking such help. hcws who reported high anxiety level were associated with living with one of the following persons living in the same residence as the hcw: an elderly person (p = 0.01), a person with chronic disease (p < 0.0001), a person with immune deficiency (p < 0.0001), or a person with respiratory disease (p < 0.0001). moreover, higher anxiety levels were if the hcw had a friend, coworker, or family member who had been diagnosed with covid-19, or they themselves had been isolated due to a suspected covid-19 infection. as expected, high anxiety levels were also associated with hcws who perceived themselves at a high risk of contracting covid-19 (p < 0.0001). table 2 presents the associations of organization factors, jobrelated factors, and preparedness of the workplace, with anxiety level. participants reporting a high level of anxiety were more likely to be working in an organization that hosts covid-19 patients and to have a job that requires dealing with such patients (p-value <0.0001). furthermore, hcws who reported that their organization provided frequent communication and updates about covid-19 and provided covid-19 tests for all hcws were less likely to have a high level of anxiety. adding to that, hcws who worked in an organization that had a documented outbreak-management plan were likely to be less anxious. using social media as a source of information for covid-19 was associated with a higher level of anxiety among the surveyed hcws. hcws who reported that the information they received from scientific and official portals or social media asnot sufficient,reported low-level anxiety (35.8%), medium-level anxiety (40.4%), and highlevel anxiety (40.9%) (p-value <0.0001). hcws also rated the quality of the information they received about covid-19 on a scale of 1-5; the hcws with low, medium, and high anxiety levels reported average scores of 3.86 (sd 1.14), 3.58, (sd 1.08), and 3.34 (sd1.19), respectively. table 3 reports the results of the multivariate regression analyses for the predictors of anxiety. after adjustment for most of the demographic and background variables, high anxiety was associated with being a smoker and having a chronic disease. among professions, nursing, radiology, and respiratory therapy were significantly associated with high anxiety. this study surveyed a large sample of hcws working in saudi arabia during the covid-19 pandemic and evaluated their level of anxiety during this time. data showed that 32.3% of hcws surveyed have a high anxiety level, and 68.5% have medium-or high-level anxiety. many factors were associated with high anxiety levels; the factors can be categorized into three themes: individual, social, and organizational. individual factors associated with high anxiety levels were being a smoker, living with a chronic disease, being a nurse, having a high self-perceived risk of getting covid-19, and previous history of anxiety. social factors that were associated with a high anxiety level were living with an elderly person, a person with chronic disease, a person with immune deficiency, or a person with respiratory disease. in addition, hcws who had a coworker, friend, or family member tested positive for covid-19 were more likely to report a high level of anxiety. organizational factors that were related to increased anxiety levels were lack of regular communication and updates from the organization, insufficient and unsatisfactory quality of information about covid-19, lack of access to covid-19 testing for the staff, and lack of a crisis management plan; these findings are consistent with other studies looking at the impact of covid-19 on the mental health of hcws [16, 17] . policymakers having to make national decisions on healthcare organizations and provisions will benefit from data generated in this and other studies looking at the impact of covid-19 on frontline workers. this study offers potential predictors of anxiety for hcws and considering these and applying strategies in crisis management plans to identify high-risk hcws will allow for better management of stress, anxiety, and mental health issues on workers. this survey offers a voice of the hcws for policy decisionmakers. ensuring regular and reliable communication of covid-19, providing ppes, and offering professional support for those already feeling anxious will reduce the burden on these hcws. several studies among hcws in other countries have found similar findings: a systematic review and meta-analysis found that nurses and female health providers had higher rates of affective symptoms than did male and medical staff; also the prevalence of insomnia was 38.9% in five studies [16] . another study from new york city, usa had surveyed 657 hcws, 33% of them had a positive screen for anxiety symptoms. nurses were also more likely than attending physicians to screen positive for anxiety (40% vs. 15% [p = 0.001]) [18] . obviously, nursing staff has longer and more close contact with patients compared to other professionals, providing the round-the-clock care that covid-19 patients need. thus, these results highlight the importance of focusing on nursing staff via monitoring and screening to detect, treat and hopefully prevent anxiety. a similar study conducted in saudi arabia in february 2020, looking at hcws anxiety levels during the covid-19 pandemic [19] . using the gad-7 anxiety scale, it found that about one-third of the studied hcws reported moderate to high anxiety; 20.8% had moderate anxiety; 8.1% had high-moderate anxiety, and 2.9% had very high anxiety. however, this study was conducted when not one case had been recorded in saudi arabia. by applying this data with table 1 healthcare worker demographic and background information in relation to anxiety level reported. our own, which recorded anxiety during the pandemic, it offers an interesting view of how anxiety levels have evolved in hcws before and during the crisis. what would be interesting is to evaluate anxiety as the numbers start to fall and lockdown restrictions start to loosen. one would predict that anxiety levels would drop in number but on the other hand, perhaps there will be an increase in hcws reporting post-traumatic stress symptoms. what is clear is that we need to support and protect our hcws at all stages of the pandemic. given the nature of a self-report survey, we wonder whether unconscious processes might have affected individuals' responses to high-stress situations. for example, that hcws who indicated that they "don't think they will get covid-19" (despite the availability of the choice "very low risk") suggests that the unconscious defense mechanism of denial played a role in their responses. not surprisingly, this group (5.3% of respondents) reported a low-level of anxiety. it is inconceivable, though, at an intellectual, logical level, that a health care practitioner would deny the possibility of getting infected. defense mechanisms are well-studied unconscious processes that protect the conscious mind from what might be overwhelming anxiety [20] . discussion of defense mechanisms that may be at work when self-reporting anxiety in such an unsettling situation is beyond the scope of this presentation, but clinicians and decision-makers should be aware of such mechanisms. another response that stood out in our survey was that married individuals and those with children below 15 years of age claimed lower levels of anxiety, which is counterintuitive to what one would think: we thought that the fear of transmitting illness to one's family might result in more distress amidst the pandemic. to expand on this, the concept of "death anxiety" is relevant. there are psychological models and psychotherapies that primarily deal with death table 2 healthcare worker response to information, job-related factors, and preparedness of the workplace according to anxiety level reported. anxiety and view it as an influential force, albeit hidden, in our psychological world [21] . undoubtedly, a pandemic of this magnitude is expected to stir this hidden anxiety. the reproductive drive that propels humankind to mating has been hypothesized to be an antidote to death anxiety [22] . in this context, we wonder if the lower levels of anxiety among married individuals and individuals with children during this unprecedented pandemic are a unique way to point to this characteristically hidden, ubiquitous worry -the worry of dying. it might be as if these persons have won rounds against death anxiety, so to speak. the higher anxiety levels among those who smoke, compared with non-smokers, also point toward thoughts about one's own mortality, should they get the infection. those who were isolated due to covid19 had a higher anxiety level, which could be related to breaking the barrier of denial, with death anxiety lurking beneath it. we believe that our research has highlighted some of the factors associated with higher levels of anxiety that could help decisionmakers and clinicians identify and offer help to practitioners who have high anxiety levels. practitioner's stress has been found associated with an increased rate of patient-safety incidents, poor quality of care due to low professionalism, and reduced patient satisfaction [23] . in our study, practitioners with high anxiety indicated they would be interested in attending online webinars on how to deal with stress, and were more likely to seek help; 24.3% of those with high anxiety level said they plan to seek help from a mental health professional after the current pandemic, while only 14.2% of hcws with high anxiety said they are currently seeking help. making mental health resources accessible and effective likely will be beneficial. this study has limitations. first, the response rate was low, and that might be attributed to the short time given to respond (only 4 days) where a busy hcw did not have time to respond, however, we think that the large sample size compensated for the low response rate and achieved the desired power. since we recruited hcws via email, those who responded may have been those interested in exploring how they feel; thus, we might have heard from the more self-aware individuals and consequently overestimated anxiety. conversely, individuals who were too overwhelmed to participate in a voluntary questionnaire might have opted out, resulting in an underestimation of anxiety. thus, given the effect of opposite forces on our results, we believe it likely that our sample is balanced. second, we grouped questions about anxiety into three categories; given the large sample size, we thought this would be the most meaningful way to interpret the data. third, the limitations of self-reporting cannot be overlooked when trying to evaluate the level of anxiety. we hope that our discussion of the unconscious considerations was an attempt to be mindful of this limitation. on the other hand, the strength of the study is that we had surveyed a large number of hcws from all the 13 regions in saudi arabia, from all different fields to be representative. also, the timing of the study was appropriate to assess the anxiety associated with covid-19, where the number of cases in the country was high. we suggest that further research on anxiety among hcws in the covid-19 pandemic include variables that were not included in our survey: level of tolerance of uncertainty; income level; beliefs about the mortality rate of covid19 and factors related to mortality rate, such as trust of the medical services in one's community to treat covid19 (intensive care unit-bed capacity, physician competency, advanced medical resources, and other variables). since we have identified the high risk groups that are more likely to develop anxiety during the covid-19 pandemic, we recommend that decision maker in healthcare institutes to be proactive and target those groups with preventative measures to avoid high level anxiety in their very precious assets in fighting the pandemic. emphasis on having a well-written outbreak management plan, effective psychological support, adequate and timely communication may help in reducing the likelihood of a stress this study is the latest and largest study conducted in saudi arabia to evaluate the anxiety levels of hcws during the covid-19 pandemic. what we can conclude is that two-thirds of the hcws who responded indicated moderate or high anxiety. consideration should be given to providing high-risk groups more psychological support and communication. a written outbreak management plan may reduce the anxiety level among hcws and their overall psychological wellbeing. the association of anxiety with other facreasons for healthcare workers becoming infected with novel coronavirus disease 2019 (covid-19) in china coronavirus disease (covid-19), weekly epidemiological update saudi ministry of health psychosocial effects of sars on hospital staff: survey of a large tertiary care institution psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in singapore severe acute respiratory syndrome (sars) in hong kong in 2003: stress and psychological impact among frontline healthcare workers the psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope the experience of the 2003 sars outbreak as a traumatic stress among frontline healthcare workers in toronto: lessons learned a nationwide survey of psychological distress among chinese people in the covid-19 epidemic: implications and policy recommendations immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china covid-19 pandemic: stress experience of healthcare workers -a short current review psychological status of medical workforce during the covid-19 pandemic: a cross-sectional study statistical power analysis for the behavioral sciences confirming the two factor model of dispositional cancer worry confirming the one-item question likert scale to measure anxiety prevalence of depression, anxiety, and insomnia among healthcare workers during the covid-19 pandemic: a systematic review and meta-analysis understanding and addressing sources of anxiety among health care professionals during the covid-19 pandemic psychological distress, coping behaviors, and preferences for support among new york healthcare workers during the covid-19 pandemic the psychological impact of covid-19 pandemic on health care workers in a mers-cov endemic country understanding defense mechanisms existential psycotherapy. 1st edition basic books, a division of harper collins publishers existential issues in sexual medicine: the relation between death anxiety and hypersexuality association between physician burnout and patient safety, professionalism, and patient satisfaction: a systematic review and metaanalysis key: cord-321193-c0g999r1 authors: goodwin, robin; wiwattanapantuwong, juthatip; tuicomepee, arunya; suttiwan, panrapee; watakakosol, rewadee title: anxiety and public responses to covid-19: early data from thailand date: 2020-06-30 journal: j psychiatr res doi: 10.1016/j.jpsychires.2020.06.026 sha: doc_id: 321193 cord_uid: c0g999r1 any new pandemic has the potential to arouse considerable anxiety, with this anxiety associated in previous work with economic disruption and societal disruption. we examined anxiety, symptom awareness, trust and associated behavioural responses in the first three weeks of the sars-cov-2 (covid-19) outbreak in thailand. we collected data on-street at randomly selected locations in bangkok. of 274 potential respondents, 203 (74.7%) responded. a four-item measure assessed anxiety, with open-ended questions assessing knowledge of symptoms, trusted information sources and measures taken to avoid infection. respondents reported good awareness of the prime symptoms of the coronovirus. binary logistic regressions controlling for sex and age found the more anxious avoided the chinese, people who were coughing, crowded places and public transport or flying. younger respondents reported greater trust in foreign media and older populations information from national government. trust in doctors online was positively associated with handwashing, avoidance of coughing people and keeping fit; trust in national government with avoiding coughing people, keeping fit, avoiding public transport and avoiding chinese people. we conclude that anxiety can motivate both desirable and undesirable behaviours during pandemic outbreaks. effective and targeted communication by trusted sources is needed to motivate preventive actions but also limit unnecessary or disruptive behaviours. anxiety, risk perceptions and behavioural responses can change rapidly during the course of a 18 pandemic (bults et al, 2011) . as the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) 19 continues to spread worldwide, effecting more and more countries, it is important to get indications 20 of the early psychological sequelae of the outbreak, and their consequences for behaviour (michie, 21 2020) . as home to the world's most visited city, and a leading destination for chinese tourists (wttc, 22 2019), thailand reported the first novel coronovirus case outside of china (on january 13 th , 2020). 23 the pandemic has had a significant economic effect, leading to a marked decline in the thai economy 24 (stevenson, 2020) . 25 in this paper we consider several key factors significant in framing responses to a developing 26 pandemic. first, we gathered knowledge about awareness of core symptoms as the virus emerged. 27 second, we consider levels of anxiety. data from china suggest the outbreak is also associated with 28 elevated levels of psychological distress (qiu et al, 2020) . we analyse changes in this anxiety over a 29 two-week time period three to five weeks after the first reported thai case. third, we consider the 30 spread of information in the emerging epidemic. close social networks (goodwin et al, 2011) , as well 31 as the wider mass media, are likely to play a crucial role in informing responses to substantial disease 32 outbreaks. finally, we combine the above to examine associations between anxiety, trust and 33 preventive behaviours. findings from previous pandemics shows that those with the greater trust 34 towards governmental communications are more likely to take recommended precautionary 35 behaviours (bults et al, 2011; bish and michie, 2010) . in common with other coronavirus outbreaks 36 including sars (washer, 2004) , and influenza strain h1n1 ('swine flu') (goodwin et al, 2011) , anxiety 37 associated with the virus has contributed towards societal disruption in thailand, as community 38 relations become strained, and groups associated with the epidemic suffer discrimination (boolert, participants. 43 research was conducted in accordance with the world medical association declaration of helsinki. 44 following ethical approval from chulalongkorn university (coa no. 052/2020), we collected data 45 between the two weeks beginning 7th-13th february 2020 and 15th-21st february. during this time 46 official cases of sars-cov-2 in thailand increased from 25 to 35. of the 50 districts of bangkok seven 47 areas within six districts were randomly selected (supplementary table 1 ). trained researcher 48 assistants approached 1 in 5 pedestrians passing a randomly pre-determined point on regional 49 shopping streets or near regional bus stations. vulnerable participants, including people appearing to 50 be younger than 18 years old or visibly pregnant, were not approached. of 272 approached, 203 51 (74.7%) gave their oral consent to the researcher and answered all questions. questionnaires totaled 52 17 items and took on average six minutes to complete. researchers conducted interviews during 53 non-rush hour times to avoid crowds and to guarantee that street noise did not prove a problem 54 during the interviews. participants ranged from 18 to over 70, with 73 (36%) male. participants were 55 subsequently grouped into <> 40, the age at which the death rate increases (worldometer, 2020) (ns 56 131 (64.5%), 72 respectively). at the end of the interview all participants were provided with the 57 latest who recommendations on avoiding catching or spreading the virus. 58 assessing awareness of symptoms, avoidance behaviours and trust in different information sources, 62 drawing on previous work on previous work on highly pathogenic zoonoses h1n1 ('swine flu') 63 (goodwin et al, 2011) , and avian influenza h7n9 (goodwin & sun, 2014) . for each question 64 participants could give multiple answers. anxiety drew on the same previous literature on zoonoses 65 and was assessed using the mean of 4, three-item scales (individual concern, concern expressed by face mask at the time of interview (n=150) we enquired about their motives for doing so. 69 70 awareness of symptoms. participants were most likely to correctly report the most frequent 72 symptoms associated with the new coronavirus (fever, cough, problems breathing) (table 1) . 73 74 anxiety. anxiety overall increased between the weeks (item ms 1.97 vs. 1.80 t (199) = 2.11 p<.04). 75 there were no sex differences in anxiety, but anxiety was higher in the younger age group (ms 1.90 76 vs. 1.67, f(1, 201) = 12.50 p=.001). personal concern was significantly associated with the perceived 77 concern of friends/family (r (201) = .48 p<.001). 78 79 behaviour, risk and trust. table 1 shows the most common responses to open-ended questions on 80 symptoms, preventive behaviours, and trust in information sources. participants were more likely to 81 be wearing masks when approached in the second week of the study (71% in week 1, 86% in week 2: 82 χ2 (1) =4.00 p=.045). 126 mentioned they wore masks due to pollution, 122 because of the virus; 83 pollution as a motive was mentioned by a similar proportion in both weeks (61%, 66% respectively), 84 but the virus motivated more mask wearing in week 2 vs. week 1 ((56.5%, (week 1) vs. 77.1% (week 85 2) reported wearing masks for fear of the coronavirus (χ2 (1) = 5.12 p< .02)). 86 87 anxiety, trust and preventive behaviours. seven binary logistic regressions, controlling for the false 88 discovery rate (benajamini & hochberg, 1995) , examined associations between each avoidance 89 behaviour and anxiety (table 2 ). controlling for sex and age grouping those most anxious were more 90 likely to avoid crowds, chinese people, those coughing, and public transport/flying. when public 91 transport use was separated from flying only the association with flying was significant (or 4.95 p=.007 (flying) vs. or 2.65 p=.06 (public transport)). there were no significant associations with 93 mask wearing or hand washing and anxiety when controlling for age and sex. twenty-four further 94 binary logistic regressions, controlling for age and sex and applying a conservative sequential holm-95 bonferroni correction (abdi, 2010), found that those who trusted doctors writing on social media 96 were more likely to report avoidance of coughing people, and keeping fit to avoid the coronavirus. 97 those who most trusted the national government reported avoiding coughing people and public 98 transport, and reported keeping fit to reduce their risk of infection (supplementary table 2 ). 99 100 as sars-cov-2 has become established in most countries around the world it is important to 102 understand the likely economic and societal implications of this spread. in this paper we conducted 103 on-street interviews during the early spread of covid-19 in thailand. we report data on awareness of 104 symptoms, anxiety, trust and associated behavioural responses three to five weeks into the epidemic 105 in this country. 106 respondents were generally aware of the key symptoms of covid-19 (fever and cough), 107 suggesting the general efficacy of public communication campaigns. anxiety levels indicated low to 108 moderate concern (mean item scores of 1.82/3, where 3 indicates highly concerned), although 109 anxiety did increase significantly between those sampled in the two-week periods of the study. novel threat. a post-doc manova analysis, using bonferroni correction with the five most frequently 119 cited sources as the dependent variables, showed a significant effect for age group on the source of 120 information most trusted. in our sample it was online doctors (f (1, 201) = 16.16 p=.001), and 121 overseas governments (f (1, 201) = 4.10 p=.044), that were the most trusted amongst younger 122 respondents. this may reflect the more limited use of internet amongst older thais (loipha, 2014) , as 123 well as a greater trust in governmental communications amongst older populations reported during 124 the h1n1 ('swine flu') pandemic (bults et al, 2011) . anxiety and trust towards different information 125 sources were associated with preventive health and economic behaviours. although public anxiety 126 may stimulate some positive actions (e.g. the avoidance of those with symptoms), it is also likely to 127 carry costs, both economic and social, as particular communities are blamed and rejected. avoidance 128 of transport/flying or commercial centers was not public policy at the time of our survey. in our study 129 anxiety about infection was associated with non-recommended economic activities, with a potential 130 7 on sars-cov-2 reports an association between higher levels of education and psychological distress 143 (qiu et al, 2020) . our respondents were mainly aged under 40, and although the population of 144 bangkok is relatively young (68.5% are aged under 40 (national statistics of thailand, 2020)), older 145 respondents could potentially be limiting their outdoor activities due to wariness of the virus. we 146 asked only a limited number of questions, and respondents varied in number of free responses 147 provided. we developed our own short measure of anxiety, meaning that we could not readily 148 compare our findings against previous established measures. this measure of anxiety had a relatively 149 modest alpha (.69). data was obtained over a short period of time within bangkok; our anxiety and 150 mask usage data reinforce the message that perceptions and behavioural motivations change rapidly 151 as a threat emerges (bults et al, 2011; fetzer et al, 2020) . we were not able to question the same 152 people over time, meaning that our data lacked the additional insights that could be provided by 153 repeated measures. at the time of data collection bangkok was the region most affected by the 154 outbreak and lower levels of anxiety and behavioural response might have been present elsewhere. 155 in the first days of a pandemic there is considerable uncertainty about spread within a specific 157 setting, as well as continuing debate over infection routes and mortality (bults et al, 2011) . we 158 believe that our early findings have an important message for those working in public health. new 159 motivations can emerge for established behaviours (such as the wearing of facemasks), suggesting 160 rapid changes in risk perception. social networks, alongside broader mass media, inform individuals 161 about both effective and less efficacious preventive behaviours. at this critical point it is vital to 162 communicate effectively about what has already been confirmed and recognize ongoing 163 uncertainties, while managing anxiety in a positive, motivating way. this may entail new strategies 164 aimed at tracking associations between public health messaging and behavioural change (holmes et 165 al, 2020) . media outlets need to be particularly careful to provide clear messaging, with social media 166 also able to connect individuals to trusted resources for psychological support to address anxiety 167 (galea et al, 2020) . it is only through doing so that societies will be able to successfully promote 168 effective precautionary behaviour and avoid economic and societal disruption as the novel zoonosis 169 continues to spread. 170 (bold are significant at p<.14 or less with statistical correction for false discovery rate: p<. 014 (benjamani & hochberg, 1995) ; controlling for week of study did not significantly affect findings) (25) respondents could provide multiple answers. controlling the false discovery rate: a practical and powerful approach to multiple testing demographic and attitudinal determinants of protective behaviours during a pandemic: a review outbreak 'reviving stereotypes perceived risk, anxiety, and behavioural responses of the general public during the early phase of the influenza a (h1n1) pandemic in the netherlands: results of three consecutive online surveys coronavirus perceptions and economic anxiety the mental health consequences of covid-19 and physical distancing: the need for prevention and early intervention the novel coronavirus (covid-2019) outbreak: amplification of public health consequences by media exposure keeping the vermin out: perceived disease threat and ideological orientations as predictors of exclusionary immigration attitudes initial psychological responses to swine flu association between media use, acute sress disorder and psychological distress representations of swine flu: perspectives from a malaysian pig farm early responses to h7n9 in southern mainland china emotional contagion multidisciplinary research priorities for the covid-19 pandemic thai elderly behavior of internet use behavioural science must be at the heart of the public health response to covid-19, bmj opinion statistical table population: bangkok a nationwide survey of psychological distress among chinese people in the covid-19 epidemic: implications and policy recommendations china stopped its economy to tackle coronavirus. now the world suffers representations of sars in the british newspapers age, sex, existing conditions of covid-19 cases and deaths one in five thai baht spent is in travel & tourism legends table 1: most common open-ended responses: treatment, preventative behaviours, vulnerability and trust table 2: associations between avoidance behaviours and anxiety, controlling for age and sex (or (95% ci) for each behaviour p value), controlling for age and sex credit author statement rg: conceptualization, methodology; software; validation; formal analysis; investigation; writing -original draft and reviewing and editing investigation; resources; data curation; writing -original draft and reviewing and editing; supervision project administration and execution; funding acquisition: ps: conceptualization, methodology, writing we acknowledge the support of the faculty of psychology at chulalongkorn university who provided 173 internal funding to recruit and train research assistants. 174 research complied with the ethical standards set out in the world medical association declaration of 176helsinki. participants, all of whom were aged over 18, gave oral consent at the time of interview, in 177 line with normal procedures for on-street interviews. the study protocol was approved by the ethics 178 committee (chulalongkorn research committee) 179 the authors have no conflicts of interest to declare. 181 internal funding was provided by the faculty of psychology at chulalongkorn university. other than 183 the authors listed on the paper the faculty had no further role in the preparation of data or the 184 manuscript. 185 rg, jw and at provided the concept and study design. jw and at acquired the data, rg and jw 187 conducted and interpreted the statistical analysis. jw, at and ps obtained funding. all authors 188 contributed to drafting and critical revision of the manuscript for intellectual content. please note that the link on evise at: http://file///k:/to%20ees/evise_projects/evise%20coi(conflict%20of%20interest)/a%20target=%22_bl ank%22%20href=%22https:/www.elsevier.com/__data/promis_misc/declaration-of-competinginterests.docx%20%22is inaccessible (file's server ip address could not be found)we are therefore making the following declaration on the basis of "all author must identify any financial and personal relationships with other people or organizations that could inappropriately influence (bias) their work or state if there are no interests to declare"we state that we have no interests to declare. key: cord-342496-4na1e2de authors: savitsky, bella; findling, yifat; ereli, anat; hendel, tova title: anxiety and coping strategies among nursing students during the covid-19 pandemic date: 2020-06-02 journal: nurse educ pract doi: 10.1016/j.nepr.2020.102809 sha: doc_id: 342496 cord_uid: 4na1e2de anxiety is highly prevalent among nursing students even in normal circumstances. in israel during the covid-19 pandemic and mandatory lockdown, nursing students encountered a new reality of economic uncertainty, fear of infection, challenges of distance education, lack of personal protection equipment (ppe) at work etc. the objective of this study was to assess levels of anxiety and ways of coping among nursing students in the ashkelon academic college, southern district, israel. a cross-sectional study was conducted among all 244 students in the nursing department during the third week of a national lockdown. anxiety level was assessed using the generalized anxiety disorder 7-item scale with a cut-off point of 10 for moderate and of 15 for severe anxiety. factor analysis was used to identify coping components. the prevalence of moderate and severe anxiety was 42.8% and 18.1% respectively. gender, lack of ppe, parental status, and fear of infection were significantly associated with a higher anxiety score. stronger self-esteem and usage of humor were associated with significantly lower anxiety levels, while mental disengagement with higher anxiety levels. the nursing department's staff may contribute in lowering student anxiety by staying in contact with students and encouraging and supporting them through this challenging period. at the time of writing (april 06,2020), the small state of israel (population 9,136,000 residents (central bureau of statistics, 2020) is in a state of lockdown with 8,611 verified cases of covid-19, 332 of them moderately or critically ill, and 106 patients on ventilators (weizman institute of science, 2020). israel is a country used to battles and our medical professionals have always been in the forefront, supporting those on the battlefield. however, this battle is different and the medical professionals have become the commanders and the foot soldiers. in the light of this situation, we decided to examine the anxiety of nursing students in these unusual times. anxiety is highly prevalent among college students. the top three concerns among students are academic performance, pressure to succeed, and post-graduation plans (beiter et al., 2015) . nursing education has been consistently associated with anxiety among students. heavy course loads, stringent examinations, continued pressure to attain a high grade point average (chernomas and shapiro, 2013) , complex interpersonal relationships, challenges of the clinical environment (chen et al., 2015) , caring for chronic and terminally ill patients (sancar, yalcin and acikgoz, 2018 ) results in greater anxiety among nursing students than among students from any of the other healthcare disciplines. anxiety has a negative effect on the quality of students' life, their education and clinical practice (sanad, 2019) . during an epidemic/pandemic, state nursing students are exposed to additional stressful factors. a study conducted among nursing students the during the sars outbreak (2003) in hong-kong showed that nursing students perceived themselves to be at higher risk of infection (wong et al., 2004) . similarly, in a study from saudi-arabia during the mers outbreak (2016), healthcare students expressed their reluctance to work in healthcare facilities with inadequate mers infection control isolation policies (elrggal et al., 2018) . in israel during the covid-19 pandemic, a state-wide mandatory closure of all institutions of learning, universities, colleges, schools and kindergartens was imposed from the beginning of march 2020 and an isolation policy was introduced by the government. only 30% of workers in both public and private sectors were allowed to continue to work (others either continued to work from home, received unpaid leave or were fired). in addition, the government mandated that all citizens had to stay within 100 meters of their home if they went out for sport, dog-walking, etc. which made it problematic to perform the most basic chores and religious activities. all stores were closed except for grocery stores, supermarkets and pharmacies. the staff of all academic institutions faced a new reality had to turn to online teaching with the aim of continuing the academic year and trying to carry out end-of-semester exams as usual. staff members started to practice and use remote reaching strategies almost immediately with the college lockdown. meanwhile students working for payment in healthcare facilities (outside of the curriculum framework) continued to work in the new reality of uncertain conditions and controversial information in relation to the new virus and often with lack of sufficient ppe. due to labor shortage in hospitals and in the community, the ministry of health's office of the director of nursing asked all nursing students in the country to voluntarily agree to work in the hospitals and community settings. as a result, more than 1,600 nursing students (100 students of them from our department (41%)) answered the call. the objective of this study was to assess level of anxiety and ways of coping during the period of covid-19 pandemic and identify association of coping strategies with characteristics of the students among nursing students in the ashkelon academic college, southern district, israel. a cross-sectional study was conducted during the third week of the lockdown among all students in the nursing department (244 students), first to fourth year of study. the questionnaire was conducted using google forms and a request to participate in the study was sent to all students. the study received approval from the ethical board of our department of nursing. the questionnaire was anonymous (demographic questions were asked but did not include identification details). filling out the questionnaire reflected consent to participate. the total response rate was 88% (215 out of 244 students -93% among the students of the first year, 95% among the second year students, 82% among the third year students and 80% among the students of the fourth, final year of studies ). the questionnaire included demographic information on students including gender, age, year of the study, family status, ethnic group, country of birth, level of religiosity and employment status (among students who worked for a salary). age was used as a continuous variable and as a dichotomic variable with the median as the cut-off point (25 years). level of religiosity was used as a categorical variable with categories: secular; traditional and religious. occupational status was used as a categorical variable with categories: salaried work in healthcare facilities; work in unrelated to the nursing field; does not work. anxiety level was assessed using the generalized anxiety disorder 7-item scale (gad-7) (löwe et al., 2008) . gad-7 was used with a suggested cut-off point of 10 for defining moderate anxiety and with a cut-off point of 15 for defining severe anxiety. this questionnaire has been widely used and is reported to have high internal consistency and good test -retest reliability among adults (zhong et al., 2015; rutter and brown, 2017), adolescents (spitzer et al., 2006) and college students (bártolo et al., 2017) . in a previous study at a cut point of 10 or greater, sensitivity and specificity exceeded 0.80, and sensitivity was nearly maximized (spitzer et al., 2006) . the internal consistency of the questionnaire was validated in this study using the cronbach's alpha (ca). ca was found 0.93 for the total sample, pointing to high internal consistency. for defining coping strategies we used coping behavior questionnaire (cope) (carver and scheier, 1989) and choose 10 items after adaptation for the current stressors. the differences in anxiety score were assessed with mann-whitney and kruskal-wallis nonparametric tests. the differences in frequency of the moderate and severe anxiety disorder by demographic sub-groups was checked with chi-square test. scores characterizing coping strategies were constructed using factor analysis with varimax rotation and an unrestricted number of factors. the following variables were included in summarizing the information regarding coping strategies of the students: four questions concerning self-esteem and ten items from the coping behavior questionnaire (cope) (carver and scheier, 1989) . variables with factor loadings ≥0.5 were considered contributing variables to a given factor and five factors were created and together explained approximately 60% of the variability ( table 1) . the first factor, referred to as "factor of self-esteem," explained 19.2% of the variance. with an increase in self-esteem of the students that they have "strong" personalities and are capable of dealing with challenges, this factor increased. the second factor, referred to as "factor of seeking information and consultation," explained 13.1% of the variance. this factor increased with escalation of seeking information and using consultations with professionals about the situation by the student. the third factor, referred to as "factor of mental disengagement" explained 9.9% of the variance. with an increase of usage of the coping strategies such as eating, consuming sedative drugs and alcohol, this factor increased. the fourth factor, referred to as "factor of spiritual and not scientific sources of support, " explained 9.8% of the variance. with an increase of belief in god and usage of social networks to get information, this factor increased. the last fifth factor, referred to as "factor of humor" explained 8.1% of the variance. with an increase of usage of humor to deal with the situation, this factor increased. after designating the factors, we used a t-test or anova test to check the association between each factor and demographic variables and a logistic regression model to investigate the associations of each factor simultaneously and after adjustment for gender with moderate and severe anxiety. statistical analyses were performed with spss statistical software version 25.0. for all analyses performed, a value of p<0.05 was considered statistically significant. the demographic characteristics of the study population are presented in table 2 . it should be noted that each year of study sees an increase in the number of married students, students with children and students working for a salary. among students who work with payment in the healthcare facilities, 69% work in a hospital and 31% work in the community setting. among students who work in healthcare facilities 50% reported that they encountered the lack of ppe at work. the percentage of students with gad-7 of 10 and above (moderate anxiety) was 42.8% (30.8% among males and 44.7% among the females, p value of x 2 test=0.21). the percentage of students with gad-7 of 15 and above (severe anxiety) was 18.1% (0% among males and 20.7% among the females, p value of x 2 test=0.006) . differences in the anxiety score was assessed by students' characteristics and presented in table 3 . males had significantly lower anxiety scores (median=7.0, iqr:1.0-11.0) in comparison with females (median=9.0, iqr:5.25-14.0) (p value=0.011). none of the other demographic characteristics were found significantly associated with the anxiety score; academic year of study was not found associated with level of anxiety. lack of ppe among working students was found associated significantly with a higher anxiety score in comparison with those students who did not experience a lack of ppe at work (median=11.0, iqr:8.0-13.5 and median=6.0, iqr:2.5-10.0 respectively) (p value=0.019). students who were more concerned with the future continuation of this academic year had a significantly higher anxiety score (median=9, iqr:6.0-14.0) than those who were concerned at a low or moderate level (median=7, iqr:2.0-12.0) (p value of mann-whitney non-parametric test=0.024) (data is not presented in the table) . the anxiety score increased among those students who are the parents of young children with the increase of the burden following the lack of educational frameworks for children (schools and kindergartens); parents who reported that they do not feel such a burden had a lower mean anxiety score than those who experienced an extreme burden (mean anxiety score was 6.5 [median=6] vs. the anxiety score was found to be positively significantly associated with dose-response relationship with fear of becoming infected (figure 1 ). the anxiety score of students who reported intense fear of infection was found significantly higher. we used logistic regression to identify the association between each of the five factors, representing coping strategies and levels of anxiety (with 10 and 15 cut-of-point respectively) as an outcome. the adjustment for gender was performed in relation to moderate anxiety only as none of males suffered from severe anxiety. table 4 presents the role of each factor. the factor of self-esteem was found significantly and negatively associated with moderate and severe anxiety: among students who perceived themselves as having strong personalities, the odds for moderate and severe anxiety were significantly lower. the factor of mental disengagement was found significantly associated with moderate and severe anxiety. the odds for moderate and severe anxiety were higher among students who reported alcohol usage, sedative drugs or excessive eating. the factor of factor of humor was found associated only with severe anxiety: the more this strategy was in use, the odds for severe anxiety were lower. coping strategies and students' characteristics (data is not presented). seeking information and consultation (factor ii) was significantly associated with the female gender (p value of t-test=0.023) and with occupational status "work as students with payment in the healthcare facilities" (p value of anova test=0.05). mental disengagement (factor iii) was significantly associated with family status "not married" (p value of t-test=0.024 for factor iii), with parental status "no children" (p value of t-test=0.013), and with level of religiosity "secular" (p value of anova test=0.001). using the coping strategy of spiritual and not scientific sources of support (factor iv) was significantly associated with age≤25 (p value of t-test=0.005), female gender (p value of t-test<0.0001), birth county "israel" (p value of t-test=0.001), population group "muslims (arabs and bedouins)" (p value of anova test=0.004), religiosity levels 'traditional" and "religious" p value of anova test<0.0001). using humor (factor v) was significantly associated with the population group "jews" (p value of anova test<0.0001) and with religiosity level "secular" (p value of anova test=0.01). the results of our study reflects anxiety at high levels among nursing students during the continuing covid-19 pandemic. according to previous studies, even in normal circumstances students experience anxiety (among university and college students, prevalence of moderate and severe anxiety was found 12.2% and 5.8% in hong-kong (lun et al., 2018) , 15.6% and 8.3% in portugal (bártolo et al., 2017) and 17.5% in australia (farrer et al., 2016) . among medical students prevalence of moderate anxiety was 25% in uk, 20% in north america, 13.7% in new-zealand and 23% in lebanon (quek et al., 2019) . anxiety level among female students was usually higher than among males in previous studies (mclean and hofmann, 2012; lun et al., 2018; mirón et al., 2019; quek et al., 2019; sanad, 2019) and was also found in our study. given the fact that females comprise the majority of our study population of nursing students, it can explain in part high the prevalence of anxiety in our study. we believe that the reason for this high prevalence of anxiety is explained by the extremely exceptional living situations and conditions during the continuing covid-19 pandemic. these circumstances include social isolation, economic instability, children who need to be taken care of at home, uncertainty about the future, challenges of remote learning, fear of getting infected and more. we did find that the anxiety score was higher as the fear of getting infected was stronger among those who encountered the lack of ppe at work and grew with the increase of concern regarding the continuation of the current academic year. as to the self-esteem factor, we found that stronger self-esteem was associated with the lowest anxiety levels (moderate and severe). our findings are consistent with the theory that people with high self-esteem presumably engage in positive, active attempts to cope with stressors (carver and scheier, 1989) . similar results were found among chinees nursing students who showed that a positive coping style is significantly correlated with a higher level of self-esteem (ni et al., 2010 (ni et al., , 2012 . in our study mental disengagement (usage of alcohol, sedative drugs and excessive eating) was associated with a higher state of anxiety. consistent with what is known about alcohol and drugs to cope with anxiety, this coping strategy is ineffective and may worsen the level of anxiety (carver and scheier, 1989) . maladaptive coping strategies are more likely to lead to eating disorders (zheng et al., 2020) . we still cannot conclude whether excessive eating in our sample represented the destructive coping strategy or whether this was a result of long home quarantine. boredom and frustration related to the lockdown may have resulted in excessive eating. usage of humor was associated in this study with lower levels of anxiety. freud's psychodynamic viewpoint described humor as one of the strongest defense mechanisms that allow individuals to face problems and avoid negative emotions and researchers believe that humor has a stress-moderating effect (penson et al., 2007) . interestingly, searching for information, was not associated with anxiety level in our study. we believe that in the particular case of the covid-19 pandemic, seeking for information might increase anxiety by overflow and multiple sources of information, sometimes broadcasting contradicting information. in our study religiosity was not associated with a lower anxiety level. numerous empirical studies have found that religion assists in an individual's ability to cope with a variety of personal and collective stressors, such as illness, the loss of a child, terrorist threats and war (bryan et al., 2016) . we believe that in particular during this period a religious lifestyle was seriously compromised following mandatory prohibitions against praying in a mosque or synagogue and using a mikveh (jewish ritual bath), the anxiety of religious people could increase. in addition, a religious lifestyle is associated with a higher birth rate (in our study the percentage of parents was twice as high among religious students in comparison with the secular group). being isolated with young children could be challenging, as we found higher anxiety level among those students who are parents and reported a heavy burden following closure of schools and kindergartens. despite the limitations of the present study related to a cross-sectional design with self-reported measures, our findings add new evidence concerning anxiety among nursing students during the 9 pandemic of covid-19. the staff of our nursing department believe that the most important way to help students during this period is to stay in continuous contact with them beyond online teaching. students face severe anxiety related to economic uncertainty, fear for health of their families, fear of infection, the need to support and care for children, and to deal with the challenges of distance education. the main goal of the department faculty is to keep in touch with students, to encourage and support them through this challenging period, which is still far from being finished as we write these words. we are planning to conduct an additional study in the near future to assess whether there has been a change in the state of anxiety of the students and their use of various coping strategies to meet the challenges of the situation. age ≤ 25 years 9.6 (5.5) 9.0 (6.0-13.0) 0.511* >26 years 9.1 (5.7) 9.0 (5.0-14.0) salaried work as a student in healthcare facilities 9.2 (5.3) 9.0 (5.0-13.0) 0.988** work unrelated to nursing field 9.2 (5.9) 9.0 (5.0-14.0) does not work 9.4 (5.4) 8.0 (6.0-12.0) ppe a supplied at work place 6.8 (5.0) 6.0 (2.5-10.0) 0.019 lack of equipment 11.6 (4.5) 11.0 (8.0-13.5) a only among students working as students with payment in the healthcare facilities * p value of mann-whitney non-parametric test ** p value of kruskal-wallis non-parametric test 1 • anxiety is highly prevalent among nursing students even in normal circumstances. • in israel during the covid-19 pandemic and mandatory lockdown, nursing students encountereda challenging reality. • the prevalence of moderate and severe anxiety was 43% and 18% respectively. • female gender, lack of protective equipment at work, and being a parent were significantly associated with higher anxiety scores. • stronger resilience and usage of humor were associated with significantly lower anxiety levels. • mental disengagement (alcohol, sedative drugs usage and excessive eating) was associated with higher anxiety levels. factor structure and construct validity of the generalized anxiety disorder 7-item (gad-7) among portuguese college students the prevalence and correlates of depression, anxiety, and stress in a sample of college students god, can i tell you something? the effect of religious coping on the relationship between anxiety over emotional expression, anxiety, and depressive symptoms assessing coping strategies : a theoretically based approach population of israel on the eve of 2020 the prevalence and related factors of depressive symptoms among junior college nursing students: a cross-sectional study stress, depression, and anxiety among undergraduate nursing students evaluation of preparedness of healthcare student volunteers against middle east respiratory syndrome coronavirus (mers-cov) in makkah, saudi arabia: a crosssectional study demographic and psychosocial predictors of major depression and generalised anxiety disorder in australian university students validation and standardization of the generalized anxiety disorder screener (gad-7) in the general population depression and anxiety among university students in hong kong gender differences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness perceived stress , anxiety and depression among undergraduate students : an online survey study relationship between coping, self-esteem, individual factors and mental health among chinese nursing students: a matched case-control study chinese female nursing students' coping strategies, self-esteem and related factors in different years of school update: laughter: the best medicine? richard', the the global prevalence of anxiety among medical students : a meta-analysis' psychometric properties of the generalized anxiety disorder scale-7 (gad-7) in outpatients with anxiety and mood disorders stress and anxiety among junior nursing students during the initial clinical training : a descriptive study at college of health sciences an examination of anxiety levels of nursing students caring for patients in terminal period we wish to thank susan holzman for her highly professional editing advices and her valuable and kind support on this project. all authors approve that they do not have any financial and personal relationships with other people, or organizations, that could inappropriately influence (bias) this research and this all authors approve that they do not have any financial and personal relationships with other people, or organizations, that could inappropriately influence (bias) this research and this manuscript. key: cord-029861-5alerret authors: wu, mengting; xu, wenyan; yao, yuhong; zhang, lei; guo, lei; fan, juan; chen, jue title: mental health status of students’ parents during covid-19 pandemic and its influence factors date: 2020-07-21 journal: gen psychiatr doi: 10.1136/gpsych-2020-100250 sha: doc_id: 29861 cord_uid: 5alerret background: during the outbreak of covid-19, the national policy of home quarantine may affect the mental health of parents. however, few studies have investigated the mental health of parents during the covid-19 pandemic. aims: to investigate the depression, anxiety and stress of the students’ parents during the covid-19 pandemic, and to explore the influence factors, especially the influence of social support and family-related factors. methods: the generalised anxiety disorder-7, patient health questionnaire-9, perceived stress scale-10 and social support rating scale were applied to 1163 parents to measure the parents’ depression, anxiety, stress and social support. results: (1) the detection rates of depression and anxiety in parents were 6.1% and 4.0%. the depression, anxiety and perceived stress of parents in central china were significantly higher than those in non-central china. the anxiety of college students’ parents was lower than that of parents of the primary, middle and high school students. the depression, anxiety and perceived stress of parents with conflicts in the family were significantly higher than those with a harmonious family. other factors that influence parents’ depression, anxiety and perceived stress include marital satisfaction, social support, parents’ history of mental illness and parenting style, etc. (2) the regression analysis results showed that perceived stress, social support, marital satisfaction, family conflicts, child’s learning stage as well as parents’ history of mental illness had significant effects on parents’ anxiety and depression. conclusion: during the covid-19 pandemic, the mental health of parents was affected by a variety of factors. good marital relationships, good social support, family harmony and parents without a history of mental illness may be protective factors for parents’ mental health, while perceived stress and child in middle or high school are risk factors for parents’ mental health. covid-19 broke out in china and became a worldwide threat in just a few months. in addition to threatening people's physical health, covid-19 brought great stress to the public and affected people's mental health. in the past, many studies have proven that individuals have strong stress responses in natural disasters or crises. 1 in a large sample survey conducted nationwide recently, 35% of the public experienced psychological distress during the outbreak of covid-19. 2 the stress response caused by such public health events is generally manifested as anxiety and depression, 3 and studies have shown that risk of depression and anxiety increases when people are in a state of long-term stress. 4 5 confirmed and suspected patients can also face long-term psychological problems after they are cured. 6 social support, as a supportive resource obtained by individuals from others or the society, is an important factor affecting individual mental health and can help individuals cope with the crisis in life. 7 as a regulator, social support had an important effect on the stress response during severe acute respiratory syndrome. 8 a recent study has shown that social support plays a moderating role between the public's acute stress and anxiety during covid-19 pandemic. 9 few studies have focused on the mental health of students' parents. since covid-19 is highly infectious, and there is still a lack of effective treatment means, the core of prevention is to reduce the crowd gathering. in the leadership of the central policy, people began a long period of home quarantine, parents and children have to work and study at home. parents and children are confined to limited space. in an online consultation during the covid-19 pandemic, parents asked many practical problems such as how to get along with children and how to deal with the conflicts with children. many parents participate in the relevant network lectures to improve communication with children, ease the family's parent-child conflicts and improve the quality of the parent-child relationship. in addition to the stress caused by the pandemic, the parent-child relationship and the relationship between parents also affect the mental health of parents in such a general psychiatry difficult period, and parents' mental health can further affect children's mental and physical health, creating a vicious circle. therefore, there is an urgent need to pay attention to the mental health of parents during the covid-19 pandemic. in summary, this study investigated the mental health of students' parents and its influence factors during the covid-19 pandemic. researchers sent online questionnaires to parents of students from primary school to college in mid-march 2020. participants were selected by purposive sampling. the participants were the primary caregivers of students and all parents volunteered to fill out the questionnaire. to ensure the quality of the questionnaires, a validity test question was set in the questionnaire, which was used to check whether the parents read the questions carefully. the validity test question requires participants to choose the fourth option. the parents who did not pass the validity test were excluded. a total of 1840 parents filled in the questionnaires, among which 98 participants were not the parents of the students, 564 participants failed the validity test question and the information of 15 parents was incomplete. in the end, 1163 valid questionnaires were obtained. the flowchart of the study is shown in figure 1 . 1. demographic information questionnaire: the self-designed demographic information questionnaire was used to collect 15 items of information, including age, gender, domicile, years of education, child's learning stage, marital status, occupation, marital satisfaction (0-100), intimacy with child (0-100), economic level of family, parents' history of mental illness, per capita housing area, parenting style, whether the parents or their family members had been quarantined for 2 weeks and whether there were family conflicts during the pandemic. 2. patient health questionnaire-9 (phq-9) 10 : it is a brief screening scale for depression that measures the depressive symptoms of individuals in the past 2 weeks. it contains nine items, and each item is rated from 0 to 3; the total scores range from 0 to 27. higher scores indicate more severe symptoms, 0-4 indicates no depressive symptoms, 5-9 indicates mild depressive symptoms, 10-14 indicates moderate depressive symptoms and 15 or above indicates severe depressive symptoms. the chinese version of the scale has good reliability and validity. 11 in this study, the cronbach's α was 0.85. 3. generalised anxiety disorder-7 (gad-7) 12 : it is a screening scale for generalised anxiety disorder that measures the anxiety symptoms of individuals in the past 2 weeks. it contains seven items, and each item is rated from 0 to 3, and the total scores range from 0 to 21. higher scores indicate more severe symptoms; 0-4 indicates no anxiety symptoms, 5-9 indicates mild anxiety symptoms, 10-14 indicates moderate anxiety symptoms and 15 or above indicates severe anxiety symptoms. the chinese version of the scale has good reliability and validity. 13 in this study, the cronbach's α was 0.91. 4. perceived stress scale-10 (pss-10) 14 : it is used to evaluate an individual's feeling of uncontrollable stress or an overload of stress, including two dimensions of negative feeling and positive feeling. it contains 10 items, and each item is rated from 1 to 5. higher scores indicate higher levels of stress. the chinese version of the scale has good reliability and validity. 15 in this study, the cronbach's α was 0.74. 5. social support rating scale (ssrs): it is used to measure the support of individuals from others or society. the scale consists of 10 items, which are divided into three dimensions: objective support, subjective support and utilisation of support. the scale has good reliability and validity. 16 in this study, the cronbach's α was 0.85. statistical analysis was done by using statistical package for the social sciences (spss v.22.0). for skewed data, the kruskal-wallis test and mann-whitney u test were used for the single-factor test. for normal data, the oneway analysis of variance was used for the test with controls for age and years of education. the relationship between depression, anxiety, stress and various factors was analysed by using spearman's correlation. ordinal regression was used to investigate the influence of multiple factors on depression and anxiety. p value < 0.05 was considered at the significant level. based on phq-9 and gad-7 scores, depression and anxiety symptoms were divided into four levels, with 0-4 indicating no symptoms, 5-9 indicating mild symptoms of depression and anxiety, 10-14 indicating moderate symptoms and 15 or above indicating severe symptoms. among the parents, mild depressive symptoms accounted for 27.3%, moderate depressive symptoms accounted for 4.6% and severe depressive symptoms accounted for 1.5%; mild anxiety symptoms accounted for 20.7%, moderate anxiety symptoms accounted for 3.4% and severe anxiety symptoms accounted for 0.5%. a score of 10 on the phq-9 and gad-7 scales was used as the dividing line for depression and anxiety. the detection rates of depression and anxiety were 6.1% and 4.0%. the detection rates of depression among parents of primary school, middle school, high school and college students were 8.4%, 5.6%, 5.2% and 4.4%, and the anxiety detection rates were 3.7%, 4.8%, 4.5% and 2.0%, respectively. the detection rates of depression among parents of central china and non-central china were 6.8% and 5.9%, and the anxiety detection rates were 5.6% and 3.7%, respectively. the total scores of phq-9, gad-7, pss-10 and ssrs were taken as dependent variables for single-factor analysis. the results showed that there were no significant differences in the levels of depression, anxiety and stress in parents of different genders. the depression and anxiety of parents in central china were significantly higher than those in non-central china (z=−2.534, p=0.011; z=−3.017, p=0.003). there were no statistically significant differences in depression, anxiety and stress in parents of different marital status. married or remarried parents had significantly higher levels of social support than divorced or widowed parents (f=52.873, p<0.001). the social support of parents in different occupations was significantly different (f=2.520, p=0.020), among which the social support of civil servants was the highest, significantly higher than that of unemployed parents. parents who had been quarantined or whose family members had been quarantined had higher levels of depression than those who had no family members quarantined (z=−2.379, p=0.017). parents with a history of mental illness had significantly higher levels of depression, anxiety and stress than parents without a history of mental illness (z=−7.820, p<0.001; z=−9.050, p<0.001; f=48.080, p<0.001), and the social support of parents with a history of mental illness was significantly lower than those without a history of mental illness (f=24.721, p<0.001). the depression, anxiety and stress of parents with medium or high family economic level were significantly lower than those with low family economic level (z=−4.012, p<0.001; z=−2.166, p=0.030; f=16.746, p<0.001), and the social support of parents with medium or high family economic level were significantly higher than those with low family economic level (f=22.761, p<0.001). there were significant differences in depression, anxiety and social support among the parents of students in different learning stages (χ 2 =24.428, p<0.001; χ 2 =24.036, p<0.001; f=11.981, p<0.001). bonferroni post hoc comparisons found that the anxiety and depression of college students' parents were significantly lower than that of the parents of students in primary, middle and high school (p=0.012, p=0.001, p<0.001; p=0.001, p=0.001, p<0.001), and the social support of the parents of students in college students was significantly higher than that of other parents (p<0.001, p=0.002, p<0.001). the depression, anxiety, stress and social support of parents with family conflicts were significantly different from those with a harmonious family (z=−10.849, p<0.001; z=−11.465, p<0.001; f=81.861, p<0.001; f=45.826, p<0.001). marital satisfaction and intimacy with child were divided into three groups based on the tertiles: high, medium and low. the results showed that the levels of depression, anxiety, stress and social support were significantly different among the three groups with different marital satisfaction (χ 2 =125.311, p<0.001; χ 2 =101.271, p<0.001; f=36.559, p<0.001; f=82.425, p<0.001). there were significant differences in levels of depression, anxiety, stress and social support among parents with different levels of intimacy with their child (χ 2 =58.186, p<0.001; χ 2 =40.261, p<0.001; f=25.361, p<0.001; f=34.070, p<0.001). parents with different parenting styles showed significant differences in depression, anxiety and stress (χ 2 =37.296, p<0.001; χ 2 =26.540, p<0.001; f=6.732, p<0.001). bonferroni post hoc comparisons found that permissive parents had significantly lower levels of depression and anxiety than authoritarian and authoritative parents (p=0.022, p<0.001). authoritarian parents had significantly higher levels of depression than authoritative parents (p<0.001) (see table 2 for details). the results of correlation analysis showed that parents' depression was negatively correlated with age, per capita housing area, social support (r=−0.116, p<0.001; r=0.079, p=0.007; r=−0.366, p<0.001) and parents' anxiety was negatively correlated with age and social support (r=−0.108, p<0.001; r=−0.305, p<0.001). anxiety and depression were significantly positively correlated to stress (r=0.571, p<0.001; r=0.521, p<0.001). the results of correlation analyses are presented in table 3. according to the scores of phq-9 and gad-7, the severity of depression and anxiety was divided into four grades (symptomless, mild, moderate and severe). the severity was taken as the dependent variable, and the scores of the pss-10 and ssrs, as well as the statistically significant factors in the univariate analysis and correlation analysis were used as the independent variables to conduct ordinal regression. the results showed that stress, marital satisfaction, social support, parents' history of mental illness, family conflicts and child's learning stage had significant effects on anxiety. stress, child in middle or high school were risk factors for anxiety (or=1.407, 2.045, 2.059, respectively). no family conflicts, high marital satisfaction, good social support and absence of mental illness history were protective factors for anxiety (or=0.500, 0.987, 0.970, 0.322, respectively) (see table 4 for details). stress, marital satisfaction, social support, parents' history of mental illness and family conflicts had significant effects on depression. stress was a risk factor for depression (or=1.226). no family conflicts, high marital satisfaction, good social support and the absence of mental illness history in parents were protective factors for depression (or=0.565, 0.990, 0.959, 0.461, respectively) (see table 5 for details). in the present study, the detection rates of anxiety and depression in students' parents were 6.1% and 4.0%, which were lower than the previous studies. [17] [18] [19] this may be because of the difference in sample composition. besides, this survey was conducted in the late period of the covid-19 pandemic, and parents' anxiety and depression may have been relieved. therefore, it can be considered that parental depression and anxiety levels were relatively low in the late period of the outbreak. this study explored the relationships between different factors and parental mental health. the study found no significant gender differences in parental anxiety, depression and stress, while past research has shown that women are more susceptible to stress than men and tend to show greater emotional responses. 20 the reason may be that the results of this study were biassed due to the small sample size of men. the previous study has found that psychological distress was highest in people of central china during the covid-19 pandemic, significantly higher than in other regions. 2 therefore, this study also compared the mental health of parents in central china and non-central china. the results showed that parents in central china had significantly higher levels of anxiety and depression than parents in non-central china. however, the stress of parents in central china was not significantly different from that in non-central china, which may be because the investigation time of this study was relatively late, the peak of the stress response has passed and the difference of stress response was transformed into the differences of depression and anxiety. parents who were quarantined or whose table 2 comparison of scores of phq-9, gad7, pss-10 and ssrs in various variables general psychiatry family members were quarantined for 2 weeks have higher levels of depression than those who had no family members being quarantined, the recent study has found that although isolation reduced the spread of the virus, it led to negative emotional experiences such as depression and anxiety. 21 mental illness of parents can significantly affect the depression, anxiety and stress of parents. on the one hand, the basis of mental illness makes parents more sensitive to the environment; on the other hand, during the pandemic, parents cannot go to the doctor normally, which further affects the mood of parents. this study focused on the influence of family related factors on the psychological status of parents and found that parents with family conflicts had significantly higher levels of depression, anxiety and stress than parents with a harmonious family. parental marital satisfaction and intimacy with their children can significantly affect parental mental health. parents with high marital satisfaction and intimacy with their children had lower levels of depression, anxiety and stress. these two factors reflect a stable and harmonious family environment. the analysis of social support also found that parents with higher marital satisfaction and intimacy with their children had better social support. this result is consistent with previous research showing that social support is influenced by the family environment, and family environment factors can influence mental health by influencing social support. 22 the depression and anxiety of college students' parents were significantly lower than that of the parents of students in other learning stages. this may be related to the social support parents received from children. the social support felt by parents of college students was significantly higher than that of other parents. college students may be an important source of social support for their parents. the depression, anxiety and stress of parents with low family economic level were significantly higher than those with high economic level, which is consistent with previous studies, family economic condition is an important factor affecting individual's mental health. 23 in the case of the pandemic, people's incomes are affected to varying degrees. families with a lower economic level will be more affected, which may lead to more stress responses, anxiety and depression among these parents. the mental health of parents with different parenting styles was also significantly different, and the anxiety, depression and stress of parents with permissive parenting styles were significantly lower than those with authoritative and authoritarian parenting styles. authoritative and authoritarian parents tend to be more demanding on their children than permissive parents. a previous study has shown that parenting styles are associated with parentchild conflicts and affect children's behaviours. 24 during the pandemic, children have to study at home, and the parents spend more time together with the children, the children's performances may not meet the requirements of these parents, which may lead to conflicts and affect the parents' emotions. correlation analysis found that parents' depression, anxiety and stress were negatively correlated with age; years of education was negatively correlated with stress level, and per capita housing area was significantly correlated with depression and stress level. further regression results showed that parents' history of mental illness, marital satisfaction, stress, social support, family conflicts and child's learning stage had significant effects on parental anxiety. stress, marital satisfaction, social support, parents' history of mental illness and family conflicts had significant effects on depression. this result indicates that stress response and social support jointly affect the depression and anxiety of individuals during the pandemic, which is consistent with the results of previous studies. 9 among family related factors, high marital satisfaction and harmonious family environment are protective factors for anxiety and depression, and the results are consistent with previous researches. chen and tian 25 found that marital satisfaction is an important factor affecting the mental health of rural women. family table 3 correlation (spearman's correlation, r) of depression, anxiety, stress and various variables relationships can affect mental health, and living in an unharmonious family can lead to anxiety and depression. 26 parents with children in middle or high school is a risk factor for anxiety, this may be because middle and high school students have heavier study tasks, and the pandemic prevents students from returning to school, so their parents may feel more anxious. first of all, in the sample selection, the researchers recruited subjects from online platforms, and the parents of the students who voluntarily filled in the survey may generally have good mental health status, so the detection rates of depression and anxiety were relatively low, and the research results are biassed to some extent. second, the survey was conducted at a relatively late stage of the pandemic, and the parents' depression, anxiety and stress response were in remission. therefore, the survey only reflects the influence of the pandemic and family relationship on parental mental health to a certain extent. this study explored the mental health status of the students' parents during home quarantine and investigated the influence of various factors on the psychological status of the parents. the results showed that parents' mental health should be paid attention to during the covid-19 epidemic, and good marriage relationship, good social support, family harmony and parents without a history of mental illness may be protective factors of parental mental health, while stress and parents with children in middle or high school are risk factors for parental mental health. this study provides an important basis for further targeted parental psychological intervention. contributors mw contributed to data analysis and manuscript writing. wx and jc designed the study and contributed to all aspects of implementation. yy helped in subject recruitment and study implementation. lz, lg and jf helped in subject recruitment and literature search. all authors contributed to and have checked the final manuscript. b, beta-value; gad-7, generalised anxiety disorder-7; phq-9, patient health questionnaire-9; pss-10, perceived stress scale-10; se, standard error; ssrs, social support rating scale. and family planning commission important disease joint research project (xhlhgg201808) a nationwide survey of psychological distress among chinese people in the covid-19 epidemic: implications and policy recommendations specialty of mood disorders and treatment during emergent events of public health study on chronic post-traumatic stress disorder, depression, anxiety symptoms of junior high school students after wenchuan earthquake the effect of acute stress disorder on negative emotions in chinese public under major epidemic conditions -the moderating effect of social support xi nan da xue xue bao zi ran ke xue ban the phq-9: a new depression diagnostic and severity measure validity and reliability of patient health questionnaire-9 and patient health questionnaire-2 to screen for depression among college students in china a brief measure for assessing generalized anxiety disorder: the gad-7 diagnostic test of screening generalized anxiety disorders in general hospital psychological department with gad-7 mermelstein r. a global measure of perceived stress depression status of community residents in karamay district of xinjiang uygar autonomous region and its influencing factors relationship among depression, anxiety and social support in elderly patients from community outpatient clinic the investigation of psychological status of medical staff during epidemic outbreak stage of sars in wuhan study on the anxiety and depression levels and influencing factors in patients with the influence of family environment and personality on college student' s social support a comparative study on the mental health of elderly population and its relation to personal income support and coping as mediators of the relation between degrading parenting and adolescent adjustment influencing factors of mental health of the elderly and their influence on children's social attributes she has started a master's program in clinical psychology in shanghai competing interests none declared. ethics approval this study was approved by the ethics committee of the shanghai mental health center affiliated to shanghai jiao tong university (number: 2020-32).provenance and peer review not commissioned; externally peer reviewed.data availability statement no additional data are available.open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ 4. 0/. key: cord-285384-xay5aw7y authors: naser, a. y.; dahmash, e. z.; al-rousan, r.; alwafi, h.; alrawashdeh, h. m.; ghoul, i.; abidine, a.; bokhary, m. a.; al-hadithi, h. t.; ali, d.; abuthawabeh, r.; abdelwahab, g. m.; alhartani, y. j.; al muhaisen, h.; dagash, a. title: mental health status of the general population, healthcare professionals, and university students during 2019 coronavirus disease outbreak in jordan: a cross-sectional study date: 2020-04-11 journal: nan doi: 10.1101/2020.04.09.20056374 sha: doc_id: 285384 cord_uid: xay5aw7y background: the emergence of covid-19 global pandemic coupled with high transmission rate and mortality has created an unprecedented state of emergency worldwide. this global situation may have a negative impact on the psychological well-being of individuals which in turn impacts individuals performance. methods: a cross-sectional study using an online survey was conducted in jordan between 22nd and 28th of march 2020 to explore the mental health status (depression and anxiety) of the general population, healthcare professionals, and university students during the covid-19 outbreak. the patient health questionnaire (phq-9) and generalized anxiety disorder-7 (gad-7) were used to assess depression and anxiety among the study participants. logistic regression analysis was used to identify predictors of depression and anxiety. results: the prevalence of depression and anxiety among the entire study participants was 23.8% and 13.1%, respectively. anxiety was most prevalent across university students 21.5%, followed by healthcare professionals 11.3%, and general population 8.8%. females among healthcare professionals and university students, divorced healthcare professionals, pulmonologists, and university students with history of chronic disease were at higher risk of developing depression. females, divorced participants among the general population, and university students with history of chronic disease and those with high income ([≥]1500 jd) were at higher risk of developing anxiety. conclusions: during outbreaks, individuals are put under extreme stressful condition resulting in higher risk of developing anxiety and depression particularly for students and healthcare professionals. policymakers and mental healthcare providers are advised to provide further mental support to these vulnerable groups during this pandemic. in december 2019, an infectious disease with unknown aetiology characterised with acute pneumonia has been recognized in wuhan, china, named 2019 coronavirus disease (wang et al., 2020) . the causative microorganism has been identified as a new rna virus from the beta-coronavirus family, named as severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (guan et al., 2020) . the respiratory illness caused by the covid-19 is highly contagious, therefore, the world health organization (who) has categorised it as a pandemic infection (who, 2020) . covid-19 is mainly transmitted through respiratory droplets and close contact, making a huge number of the population at risk of getting infected. the widespread of covid-19 mainly in wuhan, china and worldwide has attracted attention all over the world. as of april 06, 2020, a total of 1,254,969 persons were diagnosed with covid-19 and 68,825 died of this life-threating infectious disease (channel news asia, 2020). in jordan, a total of 345 cases were confirmed and 110 patients recovered with five deaths reported (channel news asia, 2020; world stats, 2020). due to duty calls, healthcare professionals (hcp) are more likely to come in contact with covid-19 carriers putting them at a greater risk of contracting the infection and spreading it to others, including their loved ones. a recent study in china reported that a total of 2,055 hcps were diagnosed with covid-19 (national health commission, 2020) . in response to covid-19 pandemic, jordan government took extremely proactive measures to prevent the spread of the virus where the state of emergency was declared on march 20, 2020. the country witnessed a complete lockdown, banning people from leaving their homes except for a few specific reasons. individual violating these orders were subject to three years in prison, a $4,200 fine, or both. the government also implemented an extensive public health awareness campaign utilizing all available media channels (the jordan times, 2020). the exponential increase in the number of cases and deaths in betterequipped countries, the spread of covid-19 misinformation, the lack of medical treatment, and the shortage of properly equipped units to care for patients all could contribute to provoking public fear, anxiety and/or depression, which is usually neglected during crisis and pandemic management (cao et al., 2020; chen et al., a cross-sectional study by means of online survey was conducted in jordan between 22 nd and 28 th of march 2020 to explore the mental health status (depression and anxiety) of the gp, hcps, and uss during the outbreak of covid-19. the data collection period was restricted to one week as longer period may influence the mentalhealth status of the study populations. a convenience sample of eligible participants was invited to participate in the study. the gp, hcps, and uss were invited to participate in this study through social media (facebook and whatsapp). each study population was invited using a specific survey-link as each population has specific demographic questions. all participants voluntarily participated in the study and were thus considered exempt from written informed consent. study aim and objectives were clearly explained at the beginning of the survey. the inclusion criteria were: a) participants aged 18 years and above and living currently in jordan; and b) participants who had no apparent cognitive deficit. participants were excluded if they were: a) below 18 years of age; b) unable to understand arabic language; and c) unable to participate due to physical or emotional distress. previously validated assessment scales, the patient health questionnaire (phq)-9 and generalized anxiety disorder 7-item (gad-7) were used to assess depression and anxiety among the study participants. these screening instruments were frequently used and validated as brief screening tools among various populations for depression and anxiety (levis, benedetti, thombs, & collaboration., 2019; löwe et al., 2008; martin, rief, klaiberg, & braehler, 2006; maurer, raymond, & davis, 2018; s. yoon et al., 2014) . in addition, the following information were collected: participants' demographics (age, gender, income, and marital status). furthermore, all participants were asked whether they were worried about being infected with covid-19 or transmitting it to family members (yes/no question). the gp and uss were asked whether they had underlying chronic conditions (yes/no question). the gp were also asked about their education level and employment status. hcps were asked about their specialities and exposure to covid-19 patients and/or providing medical care for covid-19 patients during this pandemic. uss were asked about their field of study and year level. the phq-9 scale is a 9-questions instrument given to participants to screen for the presence and severity of depression (hartung et al., 2017; hinz et al., 2016) . the gad-7 instrument was used to screen for anxiety (esser et al., 2018) . the phq-9 and the gad-7 instruments asked the participants about the degree of applicability of each item (question), using a 4-point likert scale. participants' response ranged from 0 to 3, where 0 means "not at all" and 3 means "nearly every day". the phq-9 instrument includes 9 items. items are scored from 0 to 3 generating a total score ranging from 0 to 27. a total score of 0-4 indicates minimal depression, 5-9 mild depression, 10-14 moderate depression, 15-19 moderately severe depression, and 20-27 severe depression (schwenk et al., 2011) . the gad-7 instrument includes 7 items. items are scored from 0 to 3 generating a total score ranging from 0 to 21. a total score of 5-9 indicates mild anxiety, 10-14 moderate anxiety, and 15-21 severe anxiety (spitzer, kroenke, williams, & löwe, 2006) . prevalence rates of depression and anxiety were determined using a cut-off point as recommended by the authors of the phq-9 and gad-7 scale. in this study, depression was defined as a total score of (≥ 15) in the phq-9 instrument indicating a case with moderately severe or severe depression. anxiety was defined using the gad-7 instrument with a total score of (≥ 15) indicating a case with severe anxiety. the higher the score the more severe the case identified by any scale. the prevalence rate of depression was estimated by dividing the number of participants who exceeded the borderline score (≥ 15) by the total number of the participants in the same population. prevalence rate of anxiety was calculated using the same procedure. the target sample size was estimated based on the who recommendations for the minimal sample size needed for a prevalence study (lwanga & lemeshow, 1991) . using a confidence interval of 95%, a standard deviation of 0.5, a margin of error of 5%, the required sample size was 385 participants from each study population. this study was approved by the research ethics committee at faculty of pharmacy in isra university, amman, jordan. as participation in the study was voluntary, the research ethics committee approved consent waiver. descriptive statistics were used to describe participants' demographic characteristics. continuous data were reported as mean ± sd for normally distributed variables and median (interquartile range (iqr)) for nonnormally distributed variables. categorical data were reported as percentages (frequencies). the mann-whitney u test/kruskal-wallis test was used to compare the median scores between different demographic groups. logistic regression was used to estimate odds ratios (ors) with 95% confidence intervals (cis) for anxiety or depression. logistic regression models were carried out using anxiety or depression scores above the cut-off points highlighted above. a two-sided p<0.05 was considered as statistically significant. the statistical analyses were carried out using spss (version 25). asked if they have identified any problems over the past two weeks, to what extent have these problems prevented them from doing their work, looking after their household affairs or dealing with people, 59.0% (n=2,436) reported that they faced difficulties. the prevalence of depression (participants with a total score of 15 and above; cases with moderately severe and severe depression) among the entire study participants was 23.8% (n=980). depression was most prevalent across uss (n=449, 38.6%), followed by hcps (n=247, 21.2%) and gp (n=284, 15.8%). the proportions of minimal, mild, moderate, moderately severe, and severe depression were 24.3%, 31.8%, 20.2%, 13.4%, and 10.3% respectively. the prevalence of anxiety (participants with a total score of 15 and above; cases with severe anxiety) from the entire study participants was 13.1% (n=539). similarly, anxiety was most prevalent across uss (n=250, 21.5%), followed by hcps (n=131, 11.3%) and gp (n=158, 8.8%). the proportions of mild, moderate, and severe anxiety were 35.6%, 19.0%, and 13.1% respectively. table 2 details the prevalence of depression and anxiety among participants stratified by severity. table 3 presents participant demographics data and their median depression and anxiety scores. depression median score significantly differed across participants from different demographical characteristics (p<0.05), except for the year level (for uss population). anxiety median score significantly differed across participants from different demographical characteristics (p<0.01), except for educational level (for the gp), year level and field of study (for uss population). university students, females, younger population (18-29 years), single and divorced, participants who completed their bachelor degree (from the gp), with lower-income category (500 jd and below), pulmonologist and ent specialists (for hcps), participants with no history of chronic diseases (for the gp and uss) tend to have higher depression and anxiety median scores compared to others. the logistic regression analysis identified the following group to be at a higher risk of depression: a) females among hcps and uss, b) divorced hcps, c) pulmonologist, and d) uss with chronic disease history. on the other hand, the following groups were at a lower risk of depression: a) elderly, married, and high income (1500 jd and above) participants among the gp and hcps, b) students at their fifth year of study, and c) retried participants from the gp. in addition, logistic regression analysis showed that the following groups were at a higher risk of anxiety: a) females across the three study populations, b) divorced participants among the gp, and c) uss with chronic disease history and who are with high income (1500 jd and above). on the other hand, the following groups were at a lower risk of anxiety: a) elderly and married participants among the gp, b) hcps with high income (1500 jd and above) table 4 . emerging covid-19 is a recent pandemic the has exhausted the world's resources including the lives of many. therefore, studies that investigated the impact of this novel pandemic on mental health are limited. a recent study in china investigated the effect of covid-19 on public psychological status, and reported that females were three-times at a higher risk of developing anxiety. on the other hand, higher education level was associated . cc-by-nc-nd 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . with a lower risk of developing depression by 0.39 time, these results are in-line with our study findings (wang, di, ye, & wei, 2020) . another study with 52,730 participants revealed that 35.0% of respondents experienced psychological distress during the epidemic with female respondents showing a higher risk of psychological distress when compared to males. similarly, our results showed that females demonstrated a higher risk of anxiety and depression (p<0.05) which is in-line with reported data during epidemics, where women, particularly those working in healthcare, were prone to developing depression and anxiety (lai et al., 2020; li l, 2003) . these gender differences in psychological distress including depression and anxiety have been described previously. several studies have demonstrated that female gender is a risk factor for developing mental illness where women have been reported to have 1.6 greater incidence of depression compared to men. this could be attributed to increased frequency of hormonal fluctuation in women compared to men (albert, 2015; bartels, cacioppo, van beijsterveldt, & boomsma, 2013) . in this study, a significant proportion of all participants (75.7%) emphasized their concerns about contracting covid-19 or transmitting it to family members. interestingly, although elderly are at higher risk of developing covid-19 complications, our findings demonstrated that elderly participants (≥50 years) within the gp group had a significant lower risk of developing depression (or for >50 years = 0.24, 95% ci 0.14 -0.41, p<0.000) and anxiety (or for >50 years = 0.40, 95% ci 0.22 -0.7, p<0.01) compared to younger population. possible explanation for these findings include lack of knowledge about possible complications, faith, or submission to mortality. on the other hand, mental problems were most prevalent among uss showing 38.5%, 21.5% for depression and anxiety, respectively, followed by hcps (21.2%, 11.3% respectively). the percentage of students suffering from depression and anxiety is alarming. this high prevalence rate could be primarily attributed to the mandatory switch to distance education despite the limited resources and skillsets. therefore, students had major concerns regarding the impact of this emergency situation on their education and overall school performance. interestingly, when students' category was stratified according to year level, there was a slightly higher depression and anxiety score among first-and second-year students, however, it was statistically non-significant (p>0.05). this result tallied with the findings that a statistically significant higher prevalence rate of depression and anxiety was among young adults (18-29 years, p<0.05). several studies have investigated the association between healthcare job-related stress with depression and anxiety (gao et al., 2012; mann & cowburn, 2005; smolders et al., 2009; s. l. yoon & kim, 2013) and such association appears more pronounced during a highly transmissible global pandemic such as covid-19 (lai et al., 2020) . our findings demonstrated that hcps have a higher risk of developing unfavourable mental health outcomes particularly depression and anxiety. as we anticipated, pulmonologists and ent physicians scored the highest in comparison to other hcps. potential factors that has contributed to these findings include pulmonologists and ent physicians being in the front-line in treating covid-19 patients, physician burnout, isolation form family, and feeling helpless due to the nature of this disease. similar findings are reported by wong and colleagues (2007) although ent physician score for depression and anxiety were statistically non-significant, which could be attributed to small sample size, we strongly believe that they are clinically important and should not be ignored. . cc-by-nc-nd 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . (p>0.05). furthermore, foreseeable shortages of medical supplies, personal protective equipment (ppe) and the increasing number of both suspected and confirmed cases of covid-19 contribute to the pressures and anxiety for hcps (chan-yeung, 2004) . in comparison to uss and hcps, the gp exhibited a lower prevalence rate of depression and anxiety. possible contributor to these findings include the faith that jordanians have in government. a study conducted by analyseize research demonstrated that 95.0% of jordanians have full faith in government emergency measures to combat covid-19 outbreak (analyseize research, 2020) . of note, married individuals were found to be at a lower risk of developing depression; gps (or= 0.43, 95% ci 0.33-0.55) and hcps (or= 0.75, 95% ci 0.56-0.99). previous research reported that married couples have less tendency to develop depression and anxiety compared with divorced individuals which could be attributed to the impact of marriage on wellbeing and partner support (kalmijn & monden, 2006) . furthermore, our results showed that retired individuals among the gp tend to have a lower risk of developing depression (or= 0.31, 95% ci 0.14-0.72. p<0.01) when compared to employed or unemployed individuals, which is consistent with previous studies. on one research conducted by buffel and co-worker, they reported that retired individuals tend to have a lower score of depression during crisis when compared to employed and unemployed persons (buffel, van de velde, & bracke, 2015) . during crisis there is a reported increase in unemployment rate which is positively correlated with depression rate (choudhry, enrico, & marcello, 2012; choudhry, marelli, & signorelli, 2010) . the findings of this study highlight the impact of covid-19 global pandemic on psychological well-being of individuals, particularly hcps and uss. it is our hope that these findings raise awareness amongst policy makers and mental health providers in order to take the necessary measures to attend to psychological wellbeing of individuals during global pandemic. further studies to investigate the impact of time on mental health are needed. to the best of our knowledge, this is the first and largest (4,126 participants, including 1,163 hcp) study in the middle east that investigated the prevalence of depression and anxiety during covid-19 pandemic. the large sample size increased the generalisability of these findings. additionally, the use of previously validated assessment tools is another strength of the study. however, there are some limitations. there are limited studies that explored the prevalence of depression and anxiety during covid-19 pandemic worldwide and in the middle east specifically, a fact that limited our ability to compare our findings with similar healthcare environment and culture. the sample size of ent physicians' subgroup was small due to small population in this category nationwide. the impact of time on mental health was not captured here due to the nature of this study and further studies are necessary. it would be useful to repeat the study after the covid-19 pandemic reach a peak to determine the effect of time on the results. although depression and anxiety are closely related, depression is almost related to disparate life events, and needs a longer duration in time than the 2-weeks, that are monitored by the phq-9 instrument. however, this remark is not valid for anxiety and gad-7 is relevant to the subject. the above-mentioned remarks may explain the surprising conclusion that uss are more affected and have higher depression and anxiety rates compared to hcps who are in the centre of the risk and seriously affected by this pandemic disease. finally, we used an online survey for data collection and therefore, we may have missed some of the targeted population. . cc-by-nc-nd 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/10.1101/2020.04.09.20056374 doi: medrxiv preprint however, we tackled this by distributing the survey among three different populations and widely used social media. depression and anxiety are prevalent mental problems during covid-19 pandemic. these mental problems impact the psychological wellbeing of individuals from the entire community including university students, healthcare professionals, and the general population. females, university students, divorced individuals, healthcare professionals at front-line, and those who are with underlying chronic conditions are at a higher risk. policymakers and mental care health providers are advised to attend to and provide mental support as needed to vulnerable groups during this pandemic. . cc-by-nc-nd 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https: //doi.org/10.1101 //doi.org/10. /2020 an conceived the study, wrote the methods, conducted the formal analysis, and coordinated the study. an, ezd, ha, mb, aa, ra, and hma drafted the manuscript with input from all authors. all authors have been involved in drafting the manuscript or revising it critically for important intellectual content. all authors read and approved the final manuscript. the data that support the findings of this study are available from the corresponding author upon reasonable request. . cc-by-nc-nd 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https: //doi.org/10.1101 //doi.org/10. /2020 . it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the the copyright holder for this preprint other specialities 307 ( it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the the copyright holder for this preprint higher education 6.00 9.00 5.00 6.00 year level (for university students) first year 13.00 11.00 0.14 9.00 9.00 0.22 second year 13.00 12.00 10.00 9.00 third year 12.00 11.00 9.00 9.00 fourth year 12.00 11.00 9.00 9.00 fifth year 11.00 8.00 8.00 8.00 sixth year 7.50 8.00 6.50 5.00 higher education 12.00 11.00 8.00 7.00 . cc-by-nc-nd 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https: //doi.org/10.1101 //doi.org/10. /2020 . cc-by-nc-nd 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . cc-by-nc-nd 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . cc-by-nc-nd 4.0 international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . why is depression more prevalent in women? the jordanian people and the government collectively unified against covid-19 the relation of depression and anxiety to life stress and achievement in students exploring the association between well-being and psychopathology in adolescents mental health problems in college freshmen: prevalence and academic functioning the mental health consequences of the economic crisis in europe among the employed, the unemployed, and the non-employed depression and memory impairment: a meta-analysis of the association, its pattern, and specificity academic performance of students who underwent psychiatric treatment at the students' mental health service of a brazilian university the psychological impact of the covid-19 epidemic on college students in china severe acute respiratory syndrome (sars) and healthcare workers china-who joint report on covid-19 school climate, family structure, and academic achievement: a study of moderation effects mental health of hospital consultants: the effects of stress and satisfaction at work factors influencing pharmacist performance: a review of the peer-reviewed literature umhs depression guideline. guidelines for clinical care ambulatory adherence to evidence-based guidelines for depression and anxiety disorders is associated with recording of the diagnosis a brief measure for assessing generalized anxiety disorder jordan's approach in managing coronavirus crisis physician wellness: a missing quality indicator clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan study on the public psychological states and its related factors during the outbreak of coronavirus disease 2019 (covid-19) in some regions of china who director-general's opening remarks at the media briefing on covid-19 -11 the psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope coronavirus worldwide data this study was supported by isra university (amman, jordan). the authors declare no conflict of interest. key: cord-268884-oi5l5f7f authors: shevlin, mark; mcbride, orla; murphy, jamie; miller, jilly gibson; hartman, todd k.; levita, liat; mason, liam; martinez, anton p.; mckay, ryan; stocks, thomas v. a.; bennett, kate m.; hyland, philip; karatzias, thanos; bentall, richard p. title: anxiety, depression, traumatic stress and covid-19-related anxiety in the uk general population during the covid-19 pandemic date: 2020-10-10 journal: bjpsych open doi: 10.1192/bjo.2020.109 sha: doc_id: 268884 cord_uid: oi5l5f7f background: the covid-19 pandemic has created an unprecedented global crisis, necessitating drastic changes to living conditions, social life, personal freedom and economic activity. no study has yet examined the presence of psychiatric symptoms in the uk population under similar conditions. aims: we investigated the prevalence of covid-19-related anxiety, generalised anxiety, depression and trauma symptoms in the uk population during an early phase of the pandemic, and estimated associations with variables likely to influence these symptoms. method: between 23 and 28 march 2020, a quota sample of 2025 uk adults aged 18 years and older, stratified by age, gender and household income, was recruited by online survey company qualtrics. participants completed standardised measures of depression, generalised anxiety and trauma symptoms relating to the pandemic. bivariate and multivariate associations were calculated for demographic and health-related variables. results: higher levels of anxiety, depression and trauma symptoms were reported compared with previous population studies, but not dramatically so. anxiety or depression and trauma symptoms were predicted by young age, presence of children in the home, and high estimates of personal risk. anxiety and depression were also predicted by low income, loss of income and pre-existing health conditions in self and others. specific anxiety about covid-19 was greater in older participants. conclusions: this study showed a modest increase in the prevalence of mental health problems in the early stages of the pandemic, and these problems were predicted by several specific covid-related variables. further similar surveys, particularly of those with children at home, are required as the pandemic progresses. severe acute respiratory syndrome coronavirus 2 (sars-cov-2) was first detected in wuhan, china, on 31 december 2019. the disease it causes has been named covid-19. the first uk coronavirus case was confirmed on 31 january 2020, and on 11 march 2020 the world health organization declared the global spread of covid-19 to be a pandemic. since then there have been rapidly increasing cases and deaths associated with the virus globally and in the uk. on the evening of 23 march 2020, the uk prime minister announced extensive restrictions on freedom of movement, the closure of non-essential businesses and the requirement to stay at home except for limited purposes. the mental health consequences for the population of an existential threat on the scale of the current pandemic, and of the associated restrictions on movement and social gatherings, are not well understood. there has been research on the psychological effects of other infectious respiratory diseases (irds) such as sars, the h1n1 flu pandemic and mers. however, with a few exceptions, which are mostly from the far east and have focused largely on anxiety and its influence on risk perception and health behaviours rather than mental health more broadly, 1,2 these studies have predominantly considered healthcare workers 3, 4 and patients. 5 this absence of knowledge is troubling because there is plausible evidence from modelling that emotional and behavioural responses to a pandemic may affect its course, 6 and because the burden of population mental ill-health may have implications for resources during the pandemic and national recovery afterwards. in 2003, the canadian national advisory committee on sars and public health, 7 proposed that a 'systemic perspective', which focused not only on medical staff and patients but also on the general population, should be prioritised by all those engaged in ird psychosocial research. a similar approach was advocated in a recent uk expert panel convened by the academy of medical sciences and the mental health research charity mq. 8 here, we report initial findings from the first wave of a longitudinal, multi-wave survey of the social and psychological effects of covid-19 on the uk population, conducted by researchers in seven uk and irish universities (the covid-19 psychological research consortium). 9 of note, in a mirror study with similar methodology, we recently reported the social and psychological effects of covid-19 on the population of the republic of ireland. 10 the primary aim of this study was to assess the levels of anxiety, depression and traumatic stress, based on validated selfreport measures, in a large, representative community sample during an early stage of the pandemic, between 23 and 28 march 2020. based on the scant previous studies 11 and given the dramatic restrictions imposed because of covid-19, we expected higher levels of common psychological and stress symptoms compared with previous population estimates. our secondary aim was to identify groups that are psychologically vulnerable during the pandemic, by assessing the relationship between levels of anxiety, depression and traumatic stress and (a) age; (b) household income; (c) economic threat due to covid-19; (d) health-related risk factors (being male, self or close friend or relative having a pre-existing serious health condition); (e) covid-19 infection status; (f) anxiety specifically related to covid-19; (g) perceived risk of covid-19 infection; (h) living in an urban area; (i) living as a lone adult and (j) living with children in the home. data collection started on 23 march 2020, 52 days after the first confirmed covid-19 case in the uk and on the same day that the uk prime minister announced at 8.30 pm the 'lockdown' that required all people in the uk to stay at home except for very limited purposes, and was completed on 28 march 2020. the fieldwork was conducted by the survey company qualtrics. the uk adult population aged 18 years and older was the target population, and quota sampling methods were used to ensure that the sample was representative of this population in terms of age and gender, based on 2016 population estimates from eurostat, and household income based on the 2017 office for national statistics household income bands. qualtrics provides an online platform to securely house data and leverages partners to connect with potential participants who could have been alerted to the study in one of two ways: (a) they opted to enter studies they were eligible for themselves by signing up to a panel platform; or (b) they received automatic notification through a partner router which alerted them to studies for which they were eligible (via email, sms or in-app notifications). importantly, to avoid self-selection bias, survey invitations to eligible participants only provided general information and did not include specific details about the contents of the survey. participants were required to be an adult (aged 18 years or older), able to read and write in english, and a resident of the uk. no other exclusion criteria were applied. panel members were not obliged to take part in the study. for purposes of quota sampling for age, gender and household income, qualtrics proceeded as follows during the 6 days of fieldwork: (a) respondents in 'hard to reach' quota groups (e.g. young adults in the highest income bands) were prioritised and targeted first; (b) next, the focus shifted to allow the quotas to 'fill up' naturally, without specific targeting; and (c) finally, a switch back to targeting respondents to fill incomplete quotas ensued. participants followed a link to a secure website and completed all surveys online. the invite link was active for a participant until a quota they would have qualified for was reached but after the quota was filled; previously eligible respondents were prevented from taking part in this study. participants were informed about the purpose of the study, that their data would be treated in confidence, that geolocation would be used to determine the area in which they lived, and of the right to terminate the study at any time without giving a reason. all participants provided informed consent prior to completing the survey and were directed to contact the national health service 111 covid-19 helpline at the end of the survey if they experienced any distress or had additional concerns about covid-19. ethical approval for the study was granted by the ethical review board of sheffield university (the reference number for ethical approval is 033759). qualtrics employed checks to identify and remove potential duplicate respondents or any participants who completed the survey in less than the minimum completion time (half the median time of the 'soft-launch' with 50 participants) to ensure responses were trustworthy. the pre-recruitment quotas were achieved with a high level of accuracy; the quotas were obtained to within 1 % for gender, 0.1-0.6 % for age bands and 0.25-1 % for household income bands. the 2014 adult psychiatric morbidity survey in england estimated the rate of post-traumatic stress disorder (ptsd) to be 4.4 %; 12 this was lower than the rates for anxiety and depression. to detect a disorder with a prevalence of 4 %, with precision of 1 % and a 95 % confidence level, a sample size of 1476 was required. however, estimating the prevalence of disorders with a low prevalence (<5 %) may result in a small number of 'cases' being identified. for instance, a sample size of 1476 and prevalence of 4 % will identify approximately 60 cases and, if follow-up analyses are based only on these cases, tests may be underpowered. to detect a correlation of 0.30, with alpha = 0.05 and power of 0.80, 84 cases are required (or an overall sample size of 2100). as a compromise between ensuring adequate sampling to reliably estimate prevalence and adequate power for subgroup analysis, a target sample size of 2000 participants was set. given the dual processes used by qualtrics and partners to recruit respondents to quotas, it was not possible to determine the number of survey invitations that were distributed to panel members, or indeed the number of panellists who were alerted to the survey and who did or did not complete the survey (i.e. the response rate). qualtrics did provide some metrics for the study, as follows: 159 respondents did not provide full informed consent and were screened out; 35 respondents who completed the survey from outside the uk or were aged under 18 years were also screened out; and, to ensure responses were trustworthy, 77 participants who completed the survey in less than the minimum completion time were removed, as were 64 potential duplicate respondents. this resulted in a sample of 2025 participants who completed the survey over 6 days of fieldwork. subsequent checks ensured that the participants were also representative of the population in terms of voting history, number of people in household and other important demographic characteristics. 9 participants were recruited from the four countries of the uk, proportional to their relative population sizes: england (86.9 %), wales 15 .0 % (n = 303) were in part-time employment, 16.5 % (n = 334) were retired, 4.7 % (n = 95) were students, 5.1 % (n = 103) were currently unemployed and seeking work, 3.4 % (n = 69) were not working owing to disability, and 6.6 % (n = 133) were unemployed and not seeking work. self-reported gender and age were recorded, and age was also categorised into a six-level variable for the regression analysis. participants were asked 'do you consider yourself to live in:' and were required to choose one of the options provided: 'city', 'suburb', 'town' or 'rural'. lone adult: participants were asked 'how many adults (18 years or above) live in your household (including yourself)?' and were provided with options ranging from '1' to '10 or more'. the data were recoded into a binary variable to represent living alone. participants were asked 'how many children (below the age of 18) live in your household?' and were provided with options ranging from '1' to '10 or more'. the scores were categorised into four groups (0, 1, 2, 3 or more children). participants were asked 'please choose from the following options to indicate your approximate gross (before tax is taken away) house participants were asked 'some people have lost income because of the coronavirus covid-19 pandemic, for example because they have not been able to work as much or because business contracts have been cancelled or delayed. please indicate whether your household has been affected in this way', and the response options were 'my household has lost income because of the coronavirus covid-19 pandemic', 'my household has not lost income because of the coronavirus covid-19 pandemic, and 'i do not know whether my household has lost income because of the coronavirus covid-19 pandemic'. the first option was considered as 'yes' (1) and the other options were collapsed to represent 'no'. participants were asked 'do you have diabetes, lung disease, or heart disease?', and the response options were 'yes' (1) and 'no' (0). they were also asked 'do any of your immediate family have diabetes, lung disease, or heart disease?', and the response options were 'yes' (1) and 'no' (0). participants were asked 'have you been infected by the coronavirus covid-19?', and six responses were provided. these were collapsed into a binary variable representing 'perceived infection status'. positive perceived infection status was based on the selection of either, 'i have the symptoms of the covid-19 virus and think i may have been infected' or 'i have been infected by the covid-19 virus and this has been confirmed by a test'. negative perceived infection status was based on the selection of either, 'no. i have been tested for covid-19 and the test was negative', 'no, i do not have any symptoms of covid-19', 'i have a few symptoms of cold or flu but i do not think i am infected with the covid-19 virus' or 'i may have previously been infected by covid-19 but this was not confirmed by a test and i have since recovered'. positive status (self) was coded '1' and negative status was coded as '0'. participants were also asked 'has someone close to you (a family member or friend) been infected by the coronavirus covid-19?', and four responses were provided. these were collapsed into a binary variable representing 'perceived infection statussomeone close'. positive perceived infection status was based on the selection of either, 'someone close to me has symptoms, and i suspect that person has been infected' or 'someone who is close to me has had a covid-19 virus infection confirmed by a doctor'. negative perceived infection status was based on the selection of either, 'no' or 'someone close to me has symptoms, but i am not sure if that person is infected'. positive status (other) was coded '1' and negative status was coded as '0'. participants were asked 'what do you think is your personal percentage risk of being infected with the covid-19 virus over the following time periods?', and three sliders were presented, one for each time period: (1) 'in the next month', (2) 'in the next three months', (3) 'in the next six months'? the slider had '0' and '100' at the left-and right-hand extremes, respectively, with 10 point increments, and the labels 'no risk', 'moderate risk' and 'great risk' were shown on the left-hand, middle and right-hand parts of the scale, respectively. these produced continuous scores for each time period, ranging from 0 to 100, with higher scores reflecting higher levels of perceived risk of being infected by covid-19. the scores were recoded into 'low' (0-33), 'moderate' (34-67) and 'high' (68-100). nine symptoms of depression were measured using the patient health questionnaire-9 (phq-9). 13 participants indicated how often they had been bothered by each symptom over the past 2 weeks using a four-point likert scale ranging from 0 (not at all) to 3 (nearly every day). possible scores ranged from 0 to 27, with higher scores indicative of higher levels of depression. to identify participants likely to meet the criteria for depressive disorder, a cut-off score of 10 was used. this cut-off produces adequate sensitivity (0.85) and specificity (0.89), corresponds to 'moderate' levels of depression 14 and is used to identify a level of depression that may require psychological intervention. 15 the psychometric properties of the phq-9 scores have been widely supported, and the reliability of the scale among the current sample was excellent (î± = 0.92). symptoms of generalised anxiety were measured using the generalized anxiety disorder 7-item scale (gad-7). 16 participants indicated how often they had been bothered by each symptom over the past 2 weeks on a four-point likert scale (0 = not at all, to 3 = nearly every day). possible scores ranged from 0 to 21, with higher scores indicative of higher levels of anxiety. a cut-off score of 10 was used; this has been shown to result in sensitivity of 89 % and a specificity of 82 %. 16 the gad-7 has been shown to produce reliable and valid scores in community studies, 17 and the reliability in the current sample was high (î± = 0.94). the international trauma questionnaire (itq) 18 is a self-report measure of icd-11 ptsd based on a total of six symptoms across the three symptom clusters of re-experiencing, avoidance and sense of threat: each symptom cluster comprises two symptoms. participants were asked to complete the itq 'â�¦ in relation to uk population mental health and covid-19 your experience of the covid-19 pandemic. please read each item carefully, then select one of the answers to indicate how much you have been bothered by that problem in the past month'. the ptsd symptoms are accompanied by three items measuring functional impairment caused by these symptoms. all items are answered on a five-point likert scale, ranging from 0 (not at all) to 4 (extremely), with possible scores ranging from 0 to 24. a score of â�¥2 (moderately) is considered 'endorsement' of that symptom. a ptsd diagnosis requires traumatic exposure and at least one symptom to be endorsed from each ptsd symptom cluster (re-experiencing, avoidance and sense of threat), and endorsement of at least one indicator of functional impairment. the psychometric properties of the itq scores have been demonstrated in multiple general populations 19, 20 and in clinical and high-risk samples. 21, 22 the reliability of the ptsd items was high (î± = 0.93). the survey included a question 'how anxious are you about the coronavirus covid-19 pandemic?', and the participants were provided with a 'slider' (electronic visual analogue scale) to indicate their degree of anxiety with '0' and '100' at the left-and righthand extremes, respectively, and 10 point increments. this produced continuous scores ranging from 0 to 100, with higher scores reflecting higher levels of covid-19-related anxiety. the scores were recoded into quintiles, and the upper quintile was considered to be indicative of 'covid-19 anxiety'. similar recruitment strategies and measures have been used by international collaborators in other countries, including ireland, 10 italy, spain, saudi arabia and the united arab emirates. the analyses were conducted in three linked phases. first, the prevalences of generalised anxiety, depression and traumatic stress were estimated using the established cut-off scores. second, the bivariate associations between the predictor variables and the mental health variables were calculated using logistic regression, and the associations were reported as odds ratios (ors) with 95 % confidence intervals. third, all predictor variables were entered simultaneously into multivariate binary logistic regression models to estimate the unique effect of each predictor variable, and the associations were reported as ors. based on the cut-off scores for the gad-7 and the phq-9, the prevalence of depression was 22.1 % (95 % ci 20.3-23.9 %) and that of anxiety was 21.6 % (95 % ci 19.8-23.4 %). there was no significant difference between prevalence of depression for males and females (ï� 2 (1) = 2.34, p = 0.12), but significantly more females (25.1 %) screened positive for anxiety than males (17.9 %: ï� 2 (1) = 15.48, p < 0.001). a variable was computed to represent participants who screened positive for the most common mental health disorders (anxiety/depression), either anxiety or depression; the prevalence for this was 27.7 % (95 % ci 25.8-29.7 %), and the prevalence was higher for females (31.7 %) than for males (23.4 %: (ï� 2 (1) = 17.57, p < 0.001). using the diagnostic algorithm for the itq, the prevalence of traumatic stress was 16.79 % (95 % ci 15.2-18.4 %). there was a significant gender difference, with a higher prevalence of traumatic stress for males (18.9 %) compared with females (14.9 %: ï� 2 (1) = 5.85, p < 0.01). the covid-19 anxiety prevalence was 21.3 % (95 % ci 19.5-23.1 %), and there was a significant gender difference, with a higher prevalence of covid-19 anxiety for females (24.6 %) compared with males (17.7 %: ï� 2 (1) = 5.85, p < 0.01). three binary logistic regression models were used to predict caseness on covid-19-related anxiety, anxiety/depression and traumatic stress. the predictor variables were age, gender, living location, lone adult status, number of children, income, loss of income, pre-existing health condition (self and other), covid-19 infection status (self and other) and personal risk of infection over the following month. table 1 shows the findings for covid-19-related anxiety, stratified by the predictor variables, with bivariate associations (unadjusted) presented as ors, and ors from the multivariate (adjusted) model with all predictors entered. the multivariate model was significant (ï� 2 (24) = 139.97, p < 0.001). when the unadjusted ors were calculated, only female gender, the presence of children in the household and estimates of personal risks of infection were predictive of covid-related anxiety. however, when the adjusted effects were calculated, the effect for the presence of children became stronger; there was an effect for history of infection, which should be interpreted with caution in the light of the small numbers involved; and there was a very strong effect for age, with older participants reporting more anxiety about the virus. the multivariate regression models for both anxiety/depression (ï� 2 (24) = 292.03, p < 0.001), and traumatic stress (ï� 2 (24) = 328.58, p < 0.001) were statistically significant; the unadjusted and adjusted ors are shown in tables 2 and 3 . for anxiety/depression, there was a strong effect for age, contrary to the effect observed for covidrelated anxiety, with very high levels of psychological symptoms in the youngest participants and low levels in those over 65 years of age. a bivariate effect for urban location did not survive in the multivariate model, and the effect of having children in the house was much muted in the multivariate model. participants who had lost income in the pandemic and those in the lower-income categories showed markedly higher risk for anxiety/depression. higher levels of anxiety/depression were also reported by those who had pre-existing health conditions, knew someone who had a pre-existing health condition, had become infected themselves, and/or gave a high estimate of their personal risk of infection. finally, in the case of traumatic stress, there was again a higher prevalence in younger participants, but the gender effect was reversed compared with anxiety/depression, with more symptoms being reported by males. the influence of the presence of children was marked for both the bivariate associations and the multivariate model, but there was little effect for income or loss of income when other variables were controlled for. the lack of an association for being infected by covid-19 in the multivariate model should be interpreted with caution, given the small numbers involved and the wide confidence intervals. trauma symptoms were also associated with the perception of a high risk of infection. this study was one of the first to measure psychological disorders in a representative sample of the uk population during a pandemic. the study had the additional virtues of recruiting participants early in the crisis and using standardised measures, allowing follow-up at later stages. we found higher levels of anxiety, depression and traumatic stress than those previously reported by general population-based studies. although previous studies have investigated the psychological effects of past pandemics, particularly the sars and h1n1 pandemics in the far east, they mostly considered the effects on pandemic survivors and health professionals, and the only population-based studies did not use standardised instruments. for example, a study in taiwan following the 2003 sars pandemic used a five-item symptom-rating scale, and found that poorer mental health was related to personal experience of sars shevlin et al or knowing people who had been affected. 11 in a chinese study that employed a short questionnaire during the same pandemic, respondents reported increased fear, anxiety and panic. 2 however, a longitudinal study of citizens of hong kong during the 2009 h1n1 pandemic found low levels of anxiety throughout, but anxiety levels were associated with compliance with social distancing advice. 1 our primary aim was to assess the levels of anxiety, depression and traumatic stress in the population during the early stages of the covid-19 pandemic. the prevalence of anxiety (21.63 %) and depression (22.12 %) found in this study appear to be higher than those previously reported, but not markedly so. the english 2014 adult psychiatric morbidity survey (apms) 23 reported that 15.7 % of the sample experienced symptoms of common mental health disorders, based on a cut-off score of 12 on the clinical interview schedule-revised, with a higher prevalence for women (19.1 %) than for men (12.2 %). the prevalence of anxiety or depression in the understanding society study in 2014 was 19.7 % (22.5 % for females, 16.8 % for males), 24 based on the general health questionnaire (ghq). the closest comparable study is probably the national institute for health research applied research collaboration north west coast household health survey, which administered the phq9 and gad7 (face-to-face) to 4000 people in the north-west of england, mainly living in deprived areas; in this study, 17 % were depressed and 13 % were anxious. 25 a recently published study used data from the understanding society covid-19 web survey, and reported the population prevalence of clinically significant levels of mental distress to be 27.3 %. 26 the study used the ghq to identify clinically significant distress, and data collection was approximately 1 month after our data collection period, but despite these differences the ghq prevalence was similar to that based on meeting the criteria for either anxiety or depression in this study, which was 27.7 %. this may be indicative of a stable psychological response during the first month of lockdown, although longitudinal studies will be required to determine the longitudinal change during lockdown. the prevalence of ptsd in this current study was 16.79 %, similar to the combined prevalence of ptsd and complex ptsd in a uk trauma-exposed sample (prevalence of 5.3 % for ptsd and 12.9 % for complex ptsd 27 ), and much higher than that reported by the apms (4.4 %, with no gender differences found 11 ). however, these comparisons should be treated with caution, as the status of covid-19 as a traumatic stressor is not clear. unexpectedly, the prevalence for males was higher than that for females; most epidemiological studies report a higher prevalence of ptsd for females. 28 the reasons for this are not immediately clear, but the health and economic threats that covid-19 poses may be undermining traditional male gender roles, or the higher prevalence of mortality for males during the british covid-19 pandemic may play a part. the unadjusted estimates for the model predicting anxiety/ depression revealed that younger age, being female, living in a city, pre-existing health conditions, covid-19 status and perceived risk of covid-19 infection all significantly increased the likelihood of screening positive for anxiety or depression. contrary to expectations, the oldest age group and being male were associated with a lower likelihood of anxiety or depression, despite these factors being associated with higher covid-19related mortality. 29 in the 2014 adult psychiatric morbidity survey, a much lower prevalence of common psychological disorders was observed in those over 65 compared with those of working age, although the effect was nonlinear and the high prevalence observed for those under 35 in this study were not evident there. strikingly, the opposite relationship with age was observed for anxiety specifically about the covid-19 pandemic, which was related to mortality risk in a logical way. the adjusted estimates were generally attenuated, but the same pattern of associations was found. the unadjusted estimates for the model predicting traumatic stress differed in that being male was a significant risk factor, and there was a large effect for living in an urban area. this study had both strengths and limitations. on the strengths side, the sample was highly representative of the uk population, was recruited early in the progress of the pandemic, and used standardised measures, allowing comparisons with findings from later stages of the covid-19 crisis. however, despite the sampling frame and large sample size, and although the participants in this study were representative of the uk population in terms of demographic, economic and social factors, as well as voting history, it was not a true random probability sample (which would have been very difficult to obtain under the current circumstances), and it is possible that individuals' decisions about whether to participate were affected by psychological factors, creating the possibility of sampling bias. second, all mental health assessments were based on self-report and not clinician-administered interviews; this may have resulted in overestimation of prevalence. third, the validity of the assessment of traumatic stress may be questioned, as it is not clear whether the covid-19 pandemic meets the icd-11 criteria ('an extremely threatening or horrific event or series of events') or dsm-5 criteria (direct exposure, witnessing the trauma, learning that a relative or close friend was exposed to a trauma, indirect exposure to aversive details of the trauma, usually in the course of professional duties) for a traumatic event for the entire population. this question is already being debated, 30 with arguments being made that the global nature of the threat, its wide ranging effects (i.e. health, economic and social), and the widespread reports of behaviours and cognitions modelling studies have suggested that the influence of pandemics on psychological disorders in the general population may affect the progress of a pandemic and, therefore, indirectly affect mortality. 6 furthermore, the development of psychological disorders in the population may create a burden that impedes national social and economic recovery once the pandemic ends. the fact that the prevalence of psychological problems observed in the present study was not dramatically higher than those reported in previous studies suggests that the population, at an early stage of the pandemic, has successfully adapted to the unprecedented changes that have been forced on their lifestyles. however, we have identified certain key groups who may be more vulnerable to the social and economic challenges of the pandemic, particularly those whose income has been affected, who have children living in the home and who have pre-existing health conditions that make them vulnerable to the more devastating effects of the covid-19 virus. further research is needed to track whether these groups show higher levels of psychological problems at later stages in the pandemic and whether specific interventions and policies should be developed to address their needs. the datasets generated during and/or analysed during the current study will be archived with the uk data service (https://ukdataservice.ac.uk/) within 6 months of the study ending. community psychological and behavioral responses through the first wave of the 2009 influenza a (h1n1) pandemic in hong kong changes in emotion of the chinese public in regard to the sars period psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital psychological impact of the pandemic (h1n1) 2009 on general hospital workers in kobe psychological impact on sars survivors: critical review of the english language literature modelling the influence of human behaviour on the spread of infectious diseases: a review learning from sars: renewal of public health in canada. national advisory committee on sars and public health multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science monitoring the psychological impact of the covid-19 pandemic in the general population: an overview of the context psychological research consortium (c19prc) study. psyarxiv anxiety and depression in the republic of ireland during the covid-19 pandemic populationbased post-crisis psychological distress: an example from the sars outbreak in taiwan posttraumatic stress disorder the phq-9: a new depression diagnostic and severity measure optimal cut-off score for diagnosing depression with the patient health questionnaire (phq-9): a meta-analysis national collaborating centre for mental health. improving access to psychological therapies manual a brief measure for assessing generalized anxiety disorder psychometric evaluation of the generalized anxiety disorder screener gad-7, based on a large german general population sample the international trauma questionnaire: development of a self-report measure of icd-11 ptsd and complex ptsd posttraumatic stress disorder (ptsd) and complex ptsd (cptsd) as per icd-11 proposals: a population study in israel icd-11 posttraumatic stress disorder and complex posttraumatic stress disorder in the united states: a population-based study validation of post-traumatic stress disorder (ptsd) and complex ptsd using the international trauma questionnaire an initial psychometric assessment of an icd-11 based measure of ptsd and complex ptsd (icd-tq): evidence of construct validity common mental disorders measuring national wellbeing: life in the uk do people living in disadvantaged circumstances receive different mental health treatments than those from less disadvantaged backgrounds? mental health before and during the covid-19 pandemic: a longitudinal probability sample survey of the uk population risk factors and comorbidity of icd-11 ptsd and complex ptsd: findings from a trauma-exposed population based sample of adults in the united kingdom sex and gender differences in post-traumatic stress disorder: an update updated understanding of the outbreak of 2019 novel coronavirus (2019-ncov) in wuhan traumatic stress in the age of covid-19: a call to close critical gaps and adapt to new realities associations of circadian rhythm abnormalities caused by home quarantine during the covid-19 outbreak and mental health in chinese undergraduates: evidence from a nationwide school-based survey the psychological impact of quarantine and how to reduce it: rapid review of the evidence life in the pandemic: social isolation and mental health contribution to the design of the study; drafting or revising manuscript; final approval of the version to be published; project administration. r.p.b.: conception of study; contribution to the design of the study; drafting or revising manuscript; final approval of the version to be published; project administration. this research received no specific grant from any funding agency, commercial or not-for-profit sectors. none. key: cord-320603-pus087p8 authors: ning, xianjun; yu, fang; huang, qin; li, xi; luo, yunfang; huang, qing; chen, changqing title: the mental health of neurological doctors and nurses in hunan province, china during the initial stages of the covid-19 outbreak date: 2020-09-05 journal: bmc psychiatry doi: 10.1186/s12888-020-02838-z sha: doc_id: 320603 cord_uid: pus087p8 background: neurological symptoms are increasingly being noted among covid-19 patients. currently, there is little data on the mental health of neurological healthcare workers. the aim of this study was to identify the prevalence and influencing factors on anxiety and depression in neurological healthcare workers in hunan province, china during the early stage of the coronavirus disease 2019 (covid-19) outbreak. methods: an online cross-sectional study was conducted among neurological doctors and nurses in early february 2020 in hunan province. symptoms of anxiety and depression were assessed by the chinese version of the self-rating anxiety scale (sas) (defined as a total score ≥ 50) and self-rating depression scale (sds) (defined as a total score ≥ 53). the prevalences of probable anxiety and depression were compared between different groups, and multivariate logistic regression analysis was used to understand the independent influencing factors on anxiety and depression. results: the prevalence of probable anxiety and depression in neurological nurses (20.3 and 30.2%, respectively) was higher than that in doctors (12.6 and 20.2%, respectively). female healthcare workers (18.4%) had a higher proportion of anxiety than males (10.8%). probable anxiety and depression were more prevalent among nurses, younger workers (≤ 40 years), and medical staff with junior titles. logistic regression analysis showed that a shortage of protective equipment was independently associated with probable anxiety (or = 1.980, 95% ci: 1.241–3.160, p = 0.004), while young age was a risk factor for probable depression (or = 2.293, 95% ci: 1.137–4.623, p = 0.020) among neurological healthcare workers. conclusions: probable anxiety and depression were more prevalent among neurological nurses than doctors in hunan province. the shortage of protective equipment led to probable anxiety, and young age led to probable depression in healthcare workers in neurology departments, which merits attention during the battle against covid-19. after first emerging in wuhan, china in december 2019, the 2019 novel coronavirus (2019-ncov), now dubbed covid-19, quickly spread throughout the world [1] . this new coronavirus has turned out to be much more infectious than severe acute respiratory syndrome coronavirus (sars-cov) and middle east respiratory syndrome coronavirus (mers-cov), which caused massive outbreaks [2, 3] . many clinical studies of the epidemiological and clinical characteristics of covid-19 cases have been published [4] [5] [6] . unlike sars, which mostly affected young and middle-aged people, the novel coronavirus tends to result in serious illness in elderly people, especially those with chronic diseases, such as diabetes, hypertension, and cardiovascular and cerebrovascular diseases [6, 7] . the main initial clinical manifestations include fever, cough, and shortness of breath. however, some patients do not have major symptoms, developing atypical initial symptoms in the digestive system or nervous system, which makes proper diagnosis difficult [8] . furthermore, a proportion of 2019-ncov-positive patients, have nonspecific symptoms or even are asymptomatic, a state in which the virus can still spread and cause infection [9] [10] [11] . at present, our understanding of this novel coronavirus is incomplete. respiratory droplets and person-to-person contact are defined routes of transmission for coronavirus infection, while transmission via the airborne, fecal-oral and aerosol routes remains ambiguous [12] [13] [14] . since the outbreak, a shortage of medical supplies has been a weakness in the prevention and control of the epidemic and has severely restricted the treatment of patients and threatened the safety of medical staff [15] . an epidemiological study of the first 72,314 cases of covid-19 identified on the chinese mainland from december 31, 2019, to february 11, 2020 reported that at least 3000 medical workers had been infected with 2019-ncov [1] . medical protective supplies were mainly distributed to the designated covid-19-accepting hospitals, intensive care units, and fever outpatient departments. medical personnel in general hospitals and other departments outside the front-line may be at high risk of infection because they do not have enough personal protective equipment. some studies have reported that several respiratory viruses, such as sars-cov, have the capacity to spread from the respiratory system to the central nervous system (cns), causing encephalitis and other neurological diseases [16] . recent reports of covid-19 patients in wuhan described several neurological manifestations, including headache, myalgia, nausea, dizziness, taste and smell impairment, vision impairment and neuralgia [4, 6, 17] . direct or indirect cardiotoxicity secondary to excessive systemic proinflammatory stimulation, hypercoagulability, myocardial infarction, heart failure, and arrhythmias are important risk factors for stroke in patients with covid-19 [18] . from several studies reporting covid-19 patients presenting with stroke, two patients had no covid-19-related symptoms prior to the stroke [19, 20] . if a covid-19 patient visits a neurology department with such neurologic symptoms as the initial symptom without fever or respiratory discomfort, he or she could be underdiagnosed and become a main spreader of infection. medical workers could become infected through contact with those patients. furthermore, a shortage of protective supplies and lack of training to care for patients with covid-19 contributes to the high risk of infection among neurological health care workers. unlike medical workers who are fighting on the front line, doctors and nurses in neurology departments may be less likely to receive training, including diagnostic testing for covid-19, responses to infectious diseases, and appropriate donning and removal of personnel protective equipment [21] . biological disasters have a high risk of spreading infection and increased mortality, which increases the fear of social contact, especially for health care staff who have close contact with infected patients during outbreaks [22] . it is believed that the prevention of mental health disorders should receive more attention to minimize the negative health impact of infectious diseases [23] . the experience with sars indicated that the prevalence of psychiatric morbidities, such as fear and anxiety, was high among medical workers, patients, and even the general public [24, 25] . studies are increasingly looking at the psychological impacts on the general population [14] , psychiatric patients [26] and medical health workers [27] , indicating that covid-19 does have effects on the mental health of these populations to varying degrees. currently, no studies have focused on the psychological impact on a particular group, such as neurological medical workers. mental health care for medical workers, whether working on the front line or not, should receive serious consideration. thus, the aim of this study was to investigate the mental health of medical workers in departments of neurology during the outbreak of covid-19 in hunan province. studying the psychological impact on neurology medical workers may provide valuable information for other out of front-line departments, such as ophthalmology and otolaryngology. because the investigation was performed during the covid-19 epidemic, the quarantine measures demanded less face-to-face communication and contact. therefore, self-administered anonymous electronic questionnaires were conducted on a non-commercial mobile app called "questionnaire star." in early february 2020, we distributed those questionnaires to neurological healthcare workers in hunan province via wechat, which is the most widely used social networking software in china, using a snowball sampling approach. participants were encouraged to send the questionnaire link to their colleagues whom they considered suitable for this survey. finally, effective questionnaires were returned from 650 medical workers, of which 612 were valid, including 317 doctors and 295 nurses. the protocol of this study was approved by the local ethics committee of xiangya hospital, and all participants completed the self-reported questionnaire after providing informed consent. demographic characteristics of the participants, such as age, sex, educational level, occupational title and marital status, were collected in this study. in the electronic questionnaire, the following three questions addressed respondents' perceptions of covid-19 during the outbreak: 1) do you think the department of neurology is a high-risk place for covid-19? 2) are your current precautions adequate to prevent infection? 3) are you willing to treat or care for patients with covid-19? we adopted the chinese edition of zung's self-rating depression scale (sds) and zung's self-rating anxiety scale (sas) to assess probable anxiety and depression. the widely used sas and sds scales are quick and convenient scales to evaluate anxiety and depressive symptoms of investigated subjects and are valid and efficient for the chinese population. both scales contain 20 items and are judged on a scale of 1 to 4 to assess all statements (rarely, sometimes, frequently, or always). the total crude score ranges from 20 to 80 points and is then multiplied by 1.25 to obtain a standard scale. the cut-off standard score of sas is 50 points, and a score ≥ 50 points indicates probable anxiety. meanwhile, a standard sds score ≥ 53 indicates positive depression screening. the higher the score, the higher the degree of anxiety or depression [28, 29] . the cronbach's alphas were 0.84 for sas and 0.87 for sds in the present study. statistical analysis was performed using spss 26.0 (ibm spss, chicago, il, usa). the enumeration data are presented as the numbers (n) and percentages, and the measurement data are described as the means (sd). the data between groups were compared using student's ttest and the chi-square test. the single-sample t-test was used to compare the neurology staff's scale scoring with chinese norm scoring [30] . multivariate logistic regression analysis was performed to evaluate the independent risk factors of probable anxiety and depression. significant variables identified by bivariate analysis were then entered into the regression models. the results were expressed as the odds ratios (or) with 95% confidence intervals (cis). two-tailed p values < 0.05 were considered to indicate statistical significance. the 612 neurology staff members included 317 doctors and 295 nurses. the two groups differed with respect to sex, age, education level, marital status, and occupational title. most nurses were female, with only six male nurses responding. with age stratified, 20.1% of all subjects were above 40 years and 79.9% below or equal to 40 years, and nurses were younger than doctors, with 90.5% of nurses below 40 years old. the education levels were divided into undergraduate or lower and graduate or higher. the proportion of doctors with high education was higher than that of nurses (54.6% vs. 2.4%, respectively, p < 0.001). the number of single nurses was higher than that of single doctors. the proportion of senior occupational titles in doctors was higher than that in nurses (41.6% vs. 8.5%, respectively, p < 0.001). among all participants, 210 (34.3%) agreed, 108 (17.6%) disagreed, and 294 (48.0%) were uncertain that the department of neurology was a high-risk place for covid-19 (p = 0.002), and the proportion in agreement was higher for nurses than doctors. only a few (10.9%) medical workers in the neurology department thought that the protective measures were adequate to prevent infection, with no significant difference between doctors and nurses. this may be due to the fear of infection, as some medical workers were not willing to treat or care for infected patients, and we found that the proportion of doctors expressing unwillingness was higher than nurses (p < 0.001) ( table 1) . the overall prevalence of probable anxiety and depression was 16.3 and 25.0%, respectively. nurses had a higher proportion of probable anxiety (20.3% vs. 12.6%, respectively, p = 0.010) and depression (30.2% vs. 20.2%, p = 0.004) than doctors ( table 1 ). the average sas standard score of participants was higher than the chinese national norms (41.33 ± 8.98 vs. 33.8 ± 5.9, p < 0.001). the average sds standard score of participants was 41.96 ± 11.46, which showed no significant difference when compared with the chinese national norms (41.85 ± 10.57). the prevalence of probable anxiety and depression among medical staff by basic characteristic is shown in table 2 . female medical workers had a significantly higher proportion of anxiety than males (18.4% vs. 10.8%, p = 0.025). probable anxiety and depression were more prevalent among neurological nurses, younger workers (≤ 40 years), and medical staff with junior titles (p < 0.05, respectively). we also found that workers who thought that the protective measures were not sufficient to prevent infection were more likely to report probable anxiety (p = 0.009). in further analysis, we used multivariate logistic regression analysis to identify the independent factors of probable anxiety and depression. variables showing p < 0.05 in the bivariate analysis were selected for entry into the multivariate logistic regression analysis. the results of the multivariate analysis (table 3) indicated that medical workers who disagreed that the current protective measures were adequate to prevent infection were significantly more likely to have probable anxiety (or = 1.980, 95% ci: 1.241-3.160, p = 0.004). probable depression was significantly associated with young age (≤ 40) (or = 2.293, 95% ci: 1.137-4.623, p = 0.020). this is the first study to report the prevalence of probable anxiety and depression among neurological doctors and nurses in hunan province during the covid-19 outbreak. our study found that probable anxiety and depression were more prevalent among neurological nurses than doctors. the shortage of protective equipment and young age were the main factors influencing anxiety and depression of neurological healthcare workers, respectively. in dealing with this large-scale public health emergency, healthcare workers experienced both physical and psychological pressure. a retrospective clinical study of 138 hospitalized patients from zhongnan hospital of wuhan university found that novel coronavirus pneumonia caused by hospital-related transmission was common, as 40 (29%) healthcare workers were presumed to have been infected in hospitals. of these patients with nosocomial infections, 31 (77.5%) were from the general wards, seven (17.5%) were from the emergency department, and two (5%) were from the intensive care unit (icu) [4] . what is worse, at least 3000 medical workers across the chinese mainland have been infected with the novel coronavirus during the nationwide outbreak, according to epidemiological characteristics of the 2019 covid-19 outbreak in china [1] . as the number of infected medical staff members increases, medical workers have been experiencing psychological disorders, such as anxiety, depression, phobia and sleep disturbances [31] [32] [33] . in our study, the overall prevalence of probable anxiety and depression was 16.3 and 25.0%, respectively. according to one recent meta-analysis, the pooled prevalence among healthcare workers was 16.47% for anxiety as assessed by sas and 32.81% for depression as assessed by sds [34] . in another meta-analysis, the pooled prevalence of anxiety and depression among healthcare workers was 26% (18-34%) and 25% (17-33%), respectively, but the prevalence of depression in china could be as high as 51% (48-53%) [35] . the prevalence of probable anxiety and depression was relatively lower than that for medical workers in the frontline in china, which could be explained by the heavy pressure of work and high infectious potential in their workplaces. depression was more common than anxiety in this study, which is consistent with data reported in other studies and in the above two meta-analyses. the decline in social activities and the risk of contracting covid-19, social isolation, and spending more time watching covid-19-related news, which is common during lockdown, could be the main risk factors of depression [35] . this sars-like coronavirus has the ability to use the cell entry receptor angiotensin-converting enzyme 2 (ace2) and replicate in human cells of multiple human organs, including the nervous system [36, 37] , leading to abnormally high blood pressure and increasing the risk of cerebral hemorrhage. in china, the presence of 2019-ncov in the cerebrospinal fluid was confirmed by gene sequencing of a 56-year-old patient with covid-19 in beijing [38] . the neurological symptoms of patients with covid-19 have been described in some studies. some patients were admitted to the hospital with symptoms of sudden slurred speech, limb paralysis, headache, epilepsy, or confusion [17, 21] . as general wards far from the front line, departments of neurology are also considered high-risk. in our study, 210 (34.3%) medical workers thought that the department of neurology was a high-risk place for covid-19; the proportion of doctors holding this attitude was greater than that of nurses. only 67 medical workers agreed that the current protective measures were adequate to prevent infection, accounting for 10.9% of the total. volunteer medical workers have been recruited from other departments to assist frontline medical personnel. many neurological staff members are willing to treat or care for infected patients, and the proportion holding this attitude was also higher among nurses than doctors. we found that female medical workers were more likely to develop probable anxiety than males. nurses and younger workers and those who had lower occupational titles were more prone to both anxiety and depression. our findings are generally consistent with other studies on covid-19 and previous studies on sars in 2003 [39] [40] [41] [42] , which reported that women and nurses reported more severe symptoms of anxiety and distress. furthermore, a recent meta-analysis found that women and nurses were more vulnerable to stress [35, 39] . nurses play a critically important role in the battle against covid-19, and they have a higher risk of infection due to their close contact with patients during nursing work. in our study, almost half of the doctors were women, and 98% of the nurses were women. women may be more prone to anxiety, possibly due to the high risk of infection, heavy pressure from family, and effects of female hormones [42] . moreover, 59% of all nurses had junior titles or below, indicating less work experience [39] . similarly, medical workers aged below 40 years and having lower occupational titles faced mental health disorders of anxiety and depression, probably due to insufficient experience in dealing with this public health emergency, similar to the findings in taiwan during the sars outbreak [43] . in our study, sex was not correlated with probable depression, and another study also indicated that female gender was a risk factor for anxiety but not depression [44] . in the logistic regression analysis, occupation and sex were not independently associated with mental health outcome. different studies have had different conclusions, and more studies about the mental health of healthcare workers with larger sample sizes are needed. the fear of uncertainty of the coronavirus transmission routes and the dissemination of negative information about the infection of medical staff have resulted in high levels of anxiety among medical workers. we found that the shortage of protective equipment was independently associated with anxiety. younger age was an independent risk factor for depression. since the outbreak, there has been a shortage of medical protective supplies, such as medical protective clothing, n95 masks, medical masks, protective masks, and goggles, which are urgently needed for the prevention and control of the epidemic and have severely threatened the safety of health care workers. during the covid-19 outbreak, primary protection measures were recommended in the neurology clinic and wards, while secondary protection measures were used for high-risk exposed personnel when dealing with suspected patients to alleviate the shortage of supplies [21] . nonetheless, primary protective measures like surgical masks remained in seriously short supply in neurology departments. it is difficult for neurological workers to differentiate and screen patients with manifestations of neurological systems that may be initial symptoms without fever or pulmonary disorders, which may lead to inadvertent exposure of medical staff to the virus. other sources of stress reported by another study included reduced accessibility to formal psychological support, less upto-date and accurate health information, and less intensive training on personal protective equipment and infection control measures [45] . multifaceted interventions should also be undertaken to relieve anxiety and depression among medical workers in neurology departments. first, preliminary checks and differential diagnoses of suspected cases should be firmly implemented to ensure safety at the front line. second, employees in departments of neurology should acquire indepth knowledge of infection prevention to improve compliance with hand disinfection and personal protective measures. third, with the opening of outpatient appointments, hospitals should also pay attention to medical workers out of the frontline and provide adequate protective equipment to reduce their risk of infection. fourth, we can learn from the experiences of the second xiangya hospital in hunan province and establish such resources as online courses and psychological assistance hotline teams to guide medical workers in dealing with common mental health problems and various group activities to help staff release stress [23] . workers with psychological disorders can also use online psychological self-help intervention systems to reduce symptoms of anxiety and depression [31] and apply a virtual platform characterized by mindfulness-based therapy to develop psychological resilience [46] . fifth, our government should strengthen support for and safeguard the legitimate rights and interests of medical workers during epidemic control and in the future. this study had several limitations. first, the participants were all from hunan province, the province near hubei province, limiting the generalization of our findings to other studies. second, it was limited by its use of the sas and sds to measure symptoms of anxiety and depression, which was different from a clinical diagnosis and did not measure severe psychiatric symptoms, such as suicidal ideation or psychotic experience [33] . third, the study was cross-sectional, and no cause-effect relationship can thus be established between the attitude toward covid-19 and mental health disorders. fourth, due to the limited time for designing the questionnaire, the attitude toward covid-19 only included three simple questions, lacking multi-dimensional measures. fifth, the snowballing sampling strategy was not ideal for estimating prevalence due to selection bias, and the small sample size in our study reduced its reliability. sixth, the electronic questionnaire was taken and well-accepted mainly by young people, most healthcare workers in our study were young, which may be different from our target population (all neurological clinicians in the region) and it might cause sampling bias to some extent. furthermore, influencing factors, such as history of mental health conditions or having high risk individuals in the household, were not included in this study. during the fight against covid-19 in hunan province, the shortage of protective equipment has led to probable anxiety, and young age has led to probable depression among medical staff in departments of neurology. much more attention should be paid to medical workers out of the frontline, including providing necessary protective equipment and psychological assistance. epidemiology working group for ncip epidemic response, chinese center for disease control and prevention. the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19) in china coronavirus covid-19 has killed more people than sars and mers combined, despite lower case fatality rate the sars, mers and novel coronavirus (covid-19) epidemics, the newest and biggest global health threats: what lessons have we learned? clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china clinical features of patients infected with 2019 novel coronavirus in wuhan epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study the deadly coronaviruses: the 2003 sars pandemic and the 2020 novel coronavirus epidemic in china clinical characteristics of novel coronavirus cases in tertiary hospitals in hubei province clinical and epidemiological characteristics of 34 children with 2019 novel coronavirus infection in shenzhen an update on the epidemiological characteristics of novel coronavirus pneumoniacovid-19 presumed asymptomatic carrier transmission of covid-19 importation and human-to-human transmission of a novel coronavirus in vietnam aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china mask crisis during the covid-19 outbreak human coronaviruses and other respiratory viruses: underestimated opportunistic pathogens of the central nervous system? viruses neurologic manifestations of hospitalized patients with coronavirus disease clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study large-vessel stroke as a presenting feature of covid-19 in the young covid-19 presenting as stroke consensus for prevention and management of coronavirus disease 2019 (covid-19) for neurologists the mental health of hospital workers dealing with severe acute respiratory syndrome mental health care for medical staff in china during the covid-19 outbreak psychological effects of the sars outbreak in hong kong on high-risk health care workers psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital do psychiatric patients experience more psychiatric symptoms during covid-19 pandemic and lockdown? a case-control study with service and research implications for immunopsychiatry mental health and psychosocial problems of medical health workers during the covid-19 epidemic in china a rating instrument for anxiety disorders a self-rating depression scale a survey of anxiety and depression symptoms among primary-care physicians in china online mental health services in china during the covid-19 outbreak a multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid-19 outbreak is returning to work during the covid-19 pandemic stressful? a study on immediate mental health status and psychoneuroimmunity prevention measures of chinese workforce prevalence of depression, anxiety, and insomnia among healthcare workers during the covid-19 pandemic: a systematic review and meta-analysis the psychological and mental impact of coronavirus disease 2019 (covid-19) on medical staff and general public -a systematic review and meta-analysis a pneumonia outbreak associated with a new coronavirus of probable bat origin potent binding of 2019 novel coronavirus spike protein by a sars coronavirusspecific human monoclonal antibody sars-cov-2: underestimated damage to nervous system factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019 nurses fighting against severe acute respiratory syndrome (sars) in hong kong the psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope depression, anxiety, stress levels of physicians and associated factors in covid-19 pandemics prevalence of psychiatric morbidity and psychological adaptation of the nurses in a structured sars caring unit during outbreak: a prospective and periodic assessment study in taiwan levels and predictors of anxiety, depression and health anxiety during covid-19 pandemic in turkish society: the importance of gender. the international journal of social psychiatry psychological impact of the covid-19 pandemic on health care workers in singapore mental health strategies to combat the psychological impact of covid-19 beyond paranoia and panic publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we thank letpub (www.letpub.com), editage (www.editage.cn) and aje (www.aje.com) for their linguistic assistance during the preparation of this manuscript. key: cord-333224-grjbz5u7 authors: effati-daryani, fatemeh; zarei, somayeh; mohammadi, azam; hemmati, elnaz; ghasemi yngyknd, sakineh; mirghafourvand, mojgan title: depression, stress, anxiety and their predictors in iranian pregnant women during the outbreak of covid-19 date: 2020-09-22 journal: bmc psychol doi: 10.1186/s40359-020-00464-8 sha: doc_id: 333224 cord_uid: grjbz5u7 background: pregnancy as a sensitive period of a woman’s life can be affected by various psychological factors that can have adverse effects on the woman, her fetus and future baby. since covid-19 is a new phenomenon with limited information available, it may have adverse psychological effects on pregnant women. therefore, this study was conducted to determine the status of depression, stress, anxiety and their predictors in iranian pregnant women during the outbreak of covid-19. methods: this descriptive-analytical cross-sectional study was performed on 205 pregnant women covered by tabriz health centers in iran. the sampling method used was cluster sampling. the data collection tool was the socio-demographic characteristics questionnaire and the dass-21 (depression, anxiety and stress scale-21), which were completed online by pregnant women. the general linear model was used to determine the predictive factors of depression, anxiety and stress. results: the mean (sd) score of depression, stress, and anxiety were 3.91 (3.9), 6.22 (4.25), and 3.79 (3.39), respectively; the score range of 0 to 21. depression, stress, and anxiety symptoms were observed in 32.7, 32.7, and 43.9% of the participants, respectively, with varying degrees from mild to very severe. based on the adjusted general linear model, variables of education level, spouse’s job and marital life satisfaction were the predictors of depressive symptoms. variables of spouse’s education level, spouse’s support, marital life satisfaction and the number of pregnancies were the predictive factors of anxiety symptoms and the variables of spouse’s education level, household income sufficiency, spouse’s support and marital life satisfaction were predictors of stress symptoms. conclusions: considering the role of marital life satisfaction, high level of spouse’s education and income in reducing symptoms of stress, anxiety, and depression in pregnant women in critical situations such as the prevalence of covid-19, it seems that using strategies to promote marital life satisfaction and socio-economic status can play an effective role in controlling anxiety and reducing stress and depression in pregnant women. the sars-cov-2 is a coronavirus belonging to the group of beta-coronaviruses. covid-19 is the third most well-known animal coronavirus disease after sars and mers, both of which belong to the group of betacoronaviruses [1] . the exact route of transmission of the disease is not yet known, but it is thought that covid-19 can be transmitted through droplets, close contact, aerosols, and possibly through feces-mouth, and patients in the incubation period can transfer the virus to others [2, 3] . covid-19 is rapidly advancing in the world and its mortality rate is increasing day by day. during the high prevalence of pandemics, different groups of the population, including pregnant women, as a vulnerable group, are exposed to high levels of psychological damage [4] . the unknown nature of the virus, as well as the lack of adequate information about its transmission, reproduction, risk factors, mortality, and disease-causing effects on pregnancy and the fetus [5] can pose risks not only to people's physical health but also to their mental health. it can lead to psychological effects, including stress, anxiety and depression [6] . although psychological change is one of the major changes in mothers during pregnancy, psychological care should not be neglected as these changes can lead to damage [7] ; because stress, anxiety, and depression are likely to have adverse effects on the mother and fetus. complications of stress during pregnancy include preterm labor, low birth weight, and delayed neuropsychiatric development in children born to these mothers [8] . depression during pregnancy can also have adverse effects on the fetus, the most important of which are preterm labor and low birth weight [9] . anxiety during pregnancy also increases the risk of preterm labor [10] , low birth weight [11] , preeclampsia and cesarean delivery [12] . in various studies, depression and anxiety have been reported to be about 10% during pregnancy [13] , which is considerable depending on the conditions and living environment [14] , especially in the second and third trimesters of pregnancy [15] ; it was considerable in women with a history of depression, too [16] . depressed women suffer from poor physical health and poor quality of life [17] . unfortunately, reviewing the available studies, it is found that a research investigating the pandemic effect of covid-19 disease during pregnancy and its psychological disorders was not available in iran. however, a canadian study found that pregnant women had higher levels of stress, anxiety and depression compared to the time before the covid-19 outbreak [18] . another study in turkey by durankus et al. (2020) showed that the covid-19 pandemic could cause psychological effects in pregnant women. they showed that the levels of anxiety and depression symptoms in pregnant women increased during the covid-19 pandemic [19] . in most cases, depression, anxiety, and stress are not detected or treated during pregnancy [7] . however, it is possible to improve the health of mothers and infants by identifying those women who have symptoms of anxiety and depression, and their risk factors during pregnancy [13] . consequently, considering the effects of mental disorders on pregnancy and infancy, it is possible to improve the psychological state of pregnant women, prevent complications by recognizing the psychological status of pregnant women, provide information and emotional support and other psychological interventions, and help to improve the mental state of mothers, and prevent unwanted complications. therefore, this study was conducted to determine the status of depression, stress, anxiety and their predictive factors in pregnant women during the outbreak of covid-19 in iran. this cross-sectional study was conducted after obtaining a license from the ethics committee of the vice chancellor for research and technology of tabriz university of medical sciences (code: ir.tbzme-d.rec.1398.1303) on 205 pregnant women who had a file in the health centers of tabriz-iran in 2019. tabriz is one of the metropolises of iran in which about 1897 people between march to april (the last day of sampling in this study) were identified with this disease during the covid-19 pandemic [20]. the criteria for entering the study included having a file in the health centers of tabriz, the desire to participate in the study, having a mobile phone and a healthy pregnancy. the exclusion criteria were a history of mental illness, medical problems during pregnancy, and high-risk pregnancies. sampling method was a two-step cluster sampling. twenty-two health centers (one-fourth of all health centers) selected randomly using the www.random.org website. the researcher extracted the list of pregnant women covered by the centers along with their phone numbers through the integrated health system (sib) and randomly selected the women based on the sample size determined for each center. then, the researcher made phone calls to the selected women and, while briefly explaining the objectives of the research and the confidentiality of the information, examined them in terms of eligibility criteria and, if eligible, they would participate in the study. since it was not possible to do the research in the traditional way and complete the paper questionnaire, they were asked to go online to answer the socio-demographic characteristics questionnaire, and dass-21 depression anxiety and stress questionnaire, the links of which was sent to them via whatsapp app. each participant completed the socio-demographic and obstetrics characteristics questionnaire and the dass-21 (depression, anxiety and stress scale-21) by the link to the questionnaires. the socio-demographic characteristics questionnaire included questions on age, level of education, job, spouse's age, level of education and job, sufficiency of monthly income for living expenses (this variable was measured by using a subjective item categorized in three levels including completely sufficient, fairy sufficient and insufficient), spouse's support level (this variable was measured by using a subjective item categorized in four levels including extremely high, high, moderate and poor), marital life satisfaction (this variable was measured by using a subjective item categorized in four levels including extremely high, high, moderate and poor), and obstetrics questions included the number of pregnancies, gestational age, and sex of the fetus based on ultrasound. the dass-21 is a shortened version of dass-42 and includes 21 questions and 3 subscales of stress, depression, and anxiety (7 questions for each subscale). the score for each question is a score from not at all (0) to very high (3). the score is calculated for each scale separately and the overall score is not calculated. the minimum score for each subscale is zero and the maximum is 21, and a higher score indicates a worse situation [21] . the dass21 questionnaire is commonly used in the pregnant population, especially in iran, due to the limited number of questions and simple sentences with simultaneous assessment of stress, anxiety and depression [22] . this instrument is in the public domain, and therefore, it can be freely used in research or practice [23] . this questionnaire can also be used in non-clinical populations [22, 23] . in iran, the validity of dass has been confirmed using forward-backward translation, factor analysis and criterion validity. the correlation between the beck depression inventory (bdi) and the depression subscale was 0.7, in the range of the zung self-rating anxiety scale (sas), the anxiety subscale was 0.67 and in the range of the perceived stress scale (pss), and the stress subscale was 0.49. in addition, its reliability was reported to be 0.73 for the anxiety subscale, 0.81 for the depression subscale and 0.81 for the stress subscale [24] . its reliability in pregnant women in tabriz (the setting of this study) for the variables of depression, anxiety and stress has been calculated as 0.80, 0.72 and 0.80, respectively [25] . in this study, the internal reliability using cronbach's alpha was 0.80 for the anxiety subscale, 0.78 for the depression subscale and 0.77 for the stress subscale. sample size was estimated as 97 individuals with considering d (precision) = 0.1 about the mean score of stress (m = 7.21), standard deviation = 3.63 [26] , and α = 0.05. as it was a cluster sampling, final sample size was calculated as 194 individuals with respect to the design effect of 2.0. at the end, 205 pregnant women were studied. data were analyzed using spss (version 24.0, spss inc., chicago, il). descriptive statistics including frequency, percentage, mean and standard deviation were used to describe the socio-demographic and obstetrics characteristics of the participants, depression, anxiety and stress. normal distribution of data was examined using skewness and kurtosis. the variables of depression, anxiety and stress didnot have a normal distribution. therefore, logarithmic transformation based on 10 (log 10) was used for these variables with abnormal distribution. then, the normality of log-transformed variables was checked again and all of them showed a normal distribution. general linear model test (adjusted, unadjusted) was used to determine the relationship between sociodemographic characteristics and depression, anxiety and stress. between the end of march 2020 and the beginning of april 2020, 205 people (with 40% participation) were examined. none of the participants had been affected by covid-19. the mean (standard deviation) of the participants and their spouses age were 29.3 (5.5) and 34.2 (5.6) years, respectively. about half of women (55.6%) had a university degree (44.4%) and the rest had a secondary high school and diploma degrees, and about 85% were housewives. about half of the spouses of the participants (48.3%) had a university degree and the rest (51.7%) had a high school degree, and diploma, and about half of them (45.4%) had freelance jobs. about half of women (43.9%) lived in private houses and 41.5% lived in rented houses, and about two-thirds of women (62.9%) reported relatively sufficient family income. according to ultrasound, 42% of fetuses were male. more than two-thirds of participants (70.3%) were in the second half of their pregnancy, and more than half (57.1%) experienced their first pregnancy. two-thirds reported high and very high levels of marital support (69.8) and marital life satisfaction (75.1) ( table 1) . the mean (standard deviation) score of depression, stress and anxiety were 3.91 (3.9), 6.22 (4.25) , and 3.79 (3.39), respectively, from the score range of 0 to 21. based on the scores obtained, they were divided into normal, mild, moderate, severe and very severe subgroups; 67.3% of women had normal status and 32.7% had symptoms of depression. in addition, 67.3% of people were normal in relation to stress and 32.7% of them had symptoms of stress. in the anxiety test, 56.1% of participants were normal and 43.9% of them had symptoms of anxiety ( table 2 ). the results of the present study showed no statistically significant relationship between pregnancy trimester and depression, stress and anxiety (p > 0.05). according to the unadjusted general linear model, there was a significant relationship between depression scores and spouse's level of education, spouse's job, spouse's support, and marital life satisfaction (p < 0.05). based on the adjusted general linear model, and by adjusting other variables, variables of spouse's level of education, spouse's job, and marital life satisfaction have been significantly associated with depression scores (p < 0.05) and they were able to predict 24.7% of the variance of depression score in pregnant women during the prevalence of covid-19. in addition, according to the unadjusted general linear model, there was a significant relationship between the anxiety score and the spouse's level of education, spouse's support, marital life satisfaction and the number of pregnancies (p < 0.05). based on the adjusted general linear model, and by adjusting other variables, the four variables of spouse's educational level, spouse's support, marital life satisfaction and number of pregnancies were significantly associated with the anxiety score (p < 0.05) and were able to predict 19.0% of anxiety score variance in pregnant women during the prevalence of covid-19. based on the unadjusted general linear model, there was a significant relationship between the stress score and age, education level, spouse's age, spouse's educational level, spouse's job, household income sufficiency, spouse's support, and marital life satisfaction (p < 0.05). based on the adjusted general linear model, and by adjusting other variables, the variables of spouse's level of education, sufficiency of household income, spouse's support and marital life satisfaction have a significant relationship with stress score (p < 0.05) and it was possible to predict 21.6% of stress score variance in pregnant women during the prevalence of covid-19 (table 3 ). the results of the study showed that 32.7, 32.7, and 43.9% of the participants had depression, stress and anxiety symptoms, respectively, with varying degrees from mild to very severe. based on the adjusted general linear model, variables of education level, spouse's job and marital life satisfaction were the predictors of depressive symptoms. variables of spouse's education level, spouse's support, marital life satisfaction and the number of pregnancies were the predictive factors of anxiety symptoms and the variables of spouse's education level, household income sufficiency, spouse's support and marital life satisfaction were the predictors of stress symptoms. in the present study, 67.3% of women had normal depression and stress and 32.7% had varying degrees of depression and stress. in terms of anxiety, 56.1% of people were normal, and 43.9% suffered from varying degrees of anxiety during the pandemic of sars-cov-2 disease. in line with the present study, in effati et al. [26] study on pregnant women and in a similar setting to the present study (tabriz-iran) (2018), more than half of women were normal in terms of depression, stress and anxiety and about 36, 32, and 27% of women experienced varying degrees of depression, stress, and anxiety symptoms, respectively. comparing the two groups, women's stress and depression symptoms levels were expected to be more severe during the coronavirus outbreak, while the severity of these problems was almost the same as when the coronavirus did not exist in the community. in this regard, it can be said that pregnant women, due to the importance of their fetus and its emotional attachment, may take care of themselves and follow the health advices of sars-cov-2 seriously. therefore, they should have more peace of mind and confidence, followed by less stress, anxiety and depression. during the covid-19 pandemic, the results of berthelot et al., [18] study showed that pregnant women had higher levels of stress, anxiety, and depression compared to the pregnant women who were examined before the pandemic, which is inconsistent with the results of our study. a possible reason for this discrepancy may be the cultural and social differences between our setting and their study. another study by durankus et al., (2020) [19] found that more than one-third of pregnant women had symptoms of depression and anxiety during the covid 19 pandemic, which is almost in line with the findings of our study. in a case-control study by lee et al., during the outbreak of sars, the results of anxiety in women who were pregnant during the outbreak of sars were only slightly higher than in women who were pregnant before the outbreak of sars and the rate of depression did not differ significantly between the two groups [4] . perhaps the reason for not increasing or slightly increasing of the severity of anxiety, stress and depression symptoms during the outbreak of diseases such as sars and covid-19 is that the disease is new or not taken seriously by people in the first spread. due to the newness of covid-19 disease and the lack of a study in the field, it was not possible to interpret the results of the present study in pregnant women with similar conditions in other studies. in the present study, there was a significant relationship between spouse's level of education with depression, anxiety and stress symptoms. women whose husbands had a non-university education were less likely to report depression, anxiety, and stress compared to those with a university degree. in a study by salmalian et al., [27] there was a significant association between spousal education and depression before and after childbirth, so that as the level of education was lower, depression was higher. in a study on the general population [28] , the level of education had a reverse statistical relationship with the three variables of depression, anxiety and stress. as the level of education increased, depression, stress and anxiety were reduced. the results of both studies are inconsistent with the results of the present study. education can open people's eyes and make them understand the situation, and increase their reaction to the events, especially in critical situations such as the prevalence of covid-19. while people with nonuniversity education may not have an idea of the bad condition and be less sensitive to the crisis of the outbreak of the disease, or may even be unaware of the dimensions of the crisis and the depth of the tragedy. while people with university education are expected to have more accurate follow-up of the deterioration of the situation from various sources such as scientific journals, cyberspace, media, etc. in addition, this increases the severity of depression, stress and anxiety symptoms and this causes a high level of depression, stress and anxiety in them and those around them. in our study, there was a significant relationship between spouse's job and symptoms of depression, so that women whose husbands were shopkeepers had more symptoms of depression than those whose husbands were employees. salmalian et al. [27] reported a significant relationship between spouse's job and pre and postpartum depression. depression was more common in women whose husbands had lower-paying jobs, which is consistent with our results. in the present study, there was a significant relationship between marital life satisfaction with depression, anxiety and stress scores during covid-19 prevalence. depression, stress and anxiety scores were lower in women who were satisfied and very satisfied with their lives compared to those who were moderately satisfied. in their study, bakhshi et al. [29] showed that with increasing severity of depression among men and women, their marital life satisfaction decreased. odinka et al. [30] in their study of low-risk women in the postpartum period also found a significant association between the severity of depression and anxiety and marital life satisfaction. the results of both studies were consistent with the present study. in our study, anxiety and stress scores were significantly higher in women with high levels of support from their spouses than in those with moderate levels of support. however, one study reported high anxiety and fear of childbirth in women who had poor support from their husbands or dissatisfaction with their husbands' support [31] . in addition, the results of a study showed that in 86% of pregnant women, the support of the husband during pregnancy has reduced their stress symptoms, and more than 90% of them have reported a sense of emotional security following the support of the husband [32] . the results of both studies are inconsistent with the results of our study. one of the possible causes of this mismatch could be that due to the depth of emotional relationships, high dependence and attachment to the spouse, the fear of losing him, his falling ill with covid-19 disease is greater among those supported by spouses, and this can increase their stress and anxiety. it is also possible that the stress and anxiety caused by the covid-19 pandemic in the mother will be so great that simply the support of the spouse cannot play an effective role in reducing it. in our study, anxiety scores were significantly lower in women who experienced their first and second pregnancies than in those in the third and more pregnancies. dunkel schetter et al. [33] showed a high level of pregnancy anxiety in women during their first delivery. in their study of pregnant women, rezaee et al. [34] did not report a difference in the number of parities between anxious and non-anxious women. perhaps the reason for the lower anxiety in low parity in the covid-19 pandemic in this study is the high relationship of mothers with low parity with health centers, which helps to obtain sufficient and accurate information and reduce their anxiety. according to available sources, this study is the first to investigate the depression, stress and anxiety of iranian pregnant women and their predictive factors during the prevalence of covid-19, and the random sampling of participants is another strength of the study. one of the limitations of this study is the crosssectional nature of it, the relationships shown between socio-demographic variables with symptoms of stress, depression and anxiety cannot accurately reflect the causal relationship. another limitation was that those who could have a mobile phone with internet connection could participate in this study. although 100% of the women studied had a cell phone, only 60% had a phone with this feature. therefore, as a limitation, this study may not be the representative of pregnant women in iran in general. in addition, the low level of participation was another limitation, as about half of pregnant women completed the questionnaire online. perhaps the reason for this is the recent online method of collecting data in iran, where all previous projects with pregnant women have been done in person. in the present study, marital life satisfaction and a high level of spousal education and income were associated with reduced symptoms of stress and anxiety in pregnant women. according to the results of the present study, low levels of stress, anxiety and depression in pregnant women during covid-19 prevalence can be a sign of successful training in controlling negative emotions during crisis by health centers and mass media. on the other hand, given the effective role of marital life satisfaction in reducing stress and depression in pregnant women in times of crisis, such as the prevalence of coronavirus, it seems that educating spouses about techniques for strengthening the foundation of marital life can play an effective role in controlling worries and reducing stress, anxiety and depression in pregnant women. emerging coronaviruses: genome structure, replication, and pathogenesis a new coronavirus associated with human respiratory disease in china a pneumonia outbreak associated with a new coronavirus of probable bat origin psychological responses of pregnant women to an infectious outbreak: a case-control study of the 2003 sars outbreak in hong kong coronavirus disease 2019 (covid-19) and pregnancy: what obstetricians need to know the impact of covid-19 epidemic declaration on psychological consequences: a study on active weibo users maternal depression, anxiety and stress during pregnancy and child outcome; what needs to be done stress: pregnancy considerations cohort study of the relationship between individual psychotherapy and pregnancy outcomes stress pathways to spontaneous preterm birth: the role of stressors, psychological distress, and stress hormones symptoms of anxiety and depression during pregnancy and their association with low birth weight in chinese women: a nested case control study is there an association between maternal anxiety propensity and pregnancy outcomes? factors that moderate or mediate pregnancy complications in women with anxiety and depression depression in pregnancy prevalence of depression during pregnancy: systematic review ethnic differences in stress-induced cortisol responses: increased risk for depression during pregnancy health-related quality of life among pregnant women with and without depression in hubei, china. matern child health uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic effects of the covid-19 pandemic on anxiety and depressive symptoms in pregnant women: a preliminary study the short-form version of the depression anxiety stress scales (dass-21): construct validity and normative data in a large nonclinical sample psychometric properties of the depression anxiety stress scales-21 (dass-21) in a non-clinical iranian sample the 21-item and 12-item versions of the depression anxiety stress scales: psychometric evaluation in a korean population validation of depression anxiety and stress scale (dass-21) for an iranian population association between psychological status with perceived social support in pregnant women referring to tabriz health centers depression, anxiety and stress in the various trimesters of pregnancy in women referring to tabriz health centres prevalence of pre and postpartum depression symptoms and some related factors prevalence of depression, anxiety and stress in yazd correlation between marital satisfaction and depression among couples in rafsanjan post-partum depression, anxiety and marital satisfaction: a perspective from southeastern nigeria defining childbirth fear and anxiety levels in pregnant women women's perception of husbands' support during pregnancy, labour and delivery demographic, medical, and psychosocial predictors of pregnancy anxiety predictors of mental health during pregnancy publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to thank authorities of tabriz university of medical sciences for the scientific and ethical approval and financial support of this research. we also sincerely thank all women who participated in this study.authors' contributions mm, am and fed: study concept and design, acquisition of the data, analysis and interpretation of the data, and drafting of the manuscript; fed, am, sgh and eh acquisition of the data; mm and am: critical revision of the manuscript for important intellectual content; fed, sz and am analysis and interpretation of the data, drafting of the manuscript, and statistical analysis; mm, study supervision. the author(s) read and approved the final manuscript. the authors received financial support from the tabriz university of medical sciences. the funder had no role in the study design, data collection and analysis or manuscript production. the data that support the findings of this study are not publicly available due to ongoing analyses but are available from the corresponding author, m. mirghafourvand, upon reasonable request.ethics approval and consent to participate this study was approved by the ethics committee of tabriz university of medical sciences (code: ir.tbzmed.rec.1398.1303). the informed written consent was obtained from all participants. all authors have read through the final version of the manuscript and given consent for publication in bmc psychology. all authors of this manuscript have no financial or non-financial conflicts of interest to declare. key: cord-292508-unoeicq0 authors: teshome, abinet; glagn, mustefa; shegaze, mulugeta; tekabe, beemnet; getie, asmare; assefa, genet; getahun, dinkalem; kanko, tesfaye; getachew, tamiru; yenesew, nuhamin; temtmie, zebene; tolosie, kabtamu title: generalized anxiety disorder and its associated factors among health care workers fighting covid-19 in southern ethiopia date: 2020-11-05 journal: psychol res behav manag doi: 10.2147/prbm.s282822 sha: doc_id: 292508 cord_uid: unoeicq0 background: healthcare workers (hcws) are among the many groups of people who are in the frontline caring for people and facing heavy workloads, life-or-death decisions, risk of infection, and have been facing various psychosocial problems. so, monitoring mental health issues to understand the mediating factors and inform evidence-based interventions in a timely fashion is vital. purpose: this study aimed to assess generalized anxiety disorder and its associated factors among hcws fighting covid-19 in southern ethiopia. patients and methods: an institution-based cross-sectional study was conducted among 798 hcws from 20 may to 20 june 2020. a pre-tested and structured interviewer-administered kobo collect survey tool was used to collect data. the study participants were selected using a simple random sampling technique by allocating a proportion to each health institute. the association between the level of generalized anxiety disorder and its independent variables was examined by ordinal logistic regression. assumptions for the proportional odds model were checked using parallel line tests. an adjusted proportional odds ratio with a 95% ci was used to calculate the strength of the statistical association between the independent and dependent variables. results: the prevalence of mild and moderate anxiety disorder among hcws was 29.3% and 6.3%, respectively. contact with confirmed or suspected cases (apor =1.97; 95% ci: 1.239, 3.132), no covid-19 updates (apor=4.816, 95% ci=2.957, 7.842), no confidence on coping with stresses (apor=2.74, 95% ci=1.633, 4.606), and covid-19-related worry (apor=1.85, 95% ci=1.120, 3.056) were positively associated with higher-order anxiety disorder. however, not feeling overwhelmed by the demands of everyday life (apor=0.52, 95% ci=0.370, 0.733) and feeling cannot make it (apor=0.44, 95% ci=0.308, 0.626) were negatively associated with a higher order of anxiety. conclusion: the study revealed that the prevalence of anxiety disorder among hcws was high in the study area. the findings of the current study suggest immediate psychological intervention for health care workers in the study area is vital. therefore, proactive measures should be taken by the stakeholders at different hierarchies to promote the psychological wellbeing of hcws in order to control the impact of the pandemic on the hcws, and containing the pandemic. health care workers (hcws) who are in the frontline caring for people with covid-19 infection have been facing various psychosocial problems, including a high risk of infection and inadequate protection from contamination, overwork, frustration, a lack of contact with their families, and loved ones. the severe situation is causing mental health problems such as anxiety. [1] [2] [3] generalized anxiety disorder is the most frequently occurring mental health disorder, which is characterized by excessive worry or fearfulness about events and is associated with heightened tension, nervousness, and irritability; it may cause physical symptoms such as restlessness, fatigue, muscle stiffness, and trouble concentrating or sleeping. 4, 5 the hcws are facing the pressure of working in resource-deprived settings and ever-growing patient load all over the world. 6 according to the studies conducted in the era of severe acute respiratory syndrome (sars) and ebola epidemics, the onset of a sudden and immediately lifethreatening illness could lead to extraordinary amounts of pressure on hcws and might cause adverse psychological disorders, such as anxiety, fear, and stigmatization. [7] [8] [9] [10] the other study conducted in italy reported a significant proportion of hcws experienced anxiety, depression and sleep disturbances during this psychological pressure exerts an adverse effect on the quality of care given for patients. hcws are expected to wear heavy protective garments and other personal protective equipment during pandemic like covid-19, making it much more difficult to carry out medical operations or procedures than under normal conditions. these factors, together with the fear of being contagious and infecting others, physical exhaustion, inadequate personal equipment, and the need to make ethically difficult decisions on the rationing of care could increase the possibility of psychological issues among hcws. 9,12-14 a study conducted in china reported that 13% of hcws experienced anxiety during the fight against covid-19. 15 another study conducted on the psychological impact of the covid-19 pandemic on health care workers in singapore reported a 10.8% anxiety prevalence. 16 besides, a hong kong study found that health workers suffered high anxiety scores after directly treating confirmed sars patients. 17 studies revealed that having comorbidities, living in the rural areas, being a female health worker, marital status, profession, having children, and contact with covid-19 patients were the most common risk factors for developing anxiety among health workers. 15, 16 ethiopia faces the most critical phase of the pandemic, with community transmission. hcws across the country are facing a fight like never before. frontline health-care workers, faced with heavy workloads, life-or-death decisions, and risk of infection, are particularly affected. 18 even though there are some studies conducted on the psychosocial impact of covid-19 and its associated factors globally, it is a new disease and the medical system and culture of different countries vary which necessitates the need for further research on the psychological experience of frontline health workers fighting against covid-19 . currently, as far as our literature search is concerned, there are no published studies on anxiety related to covid-19 in ethiopia in general and southern region in particular. therefore, this study aimed to assess generalized anxiety disorder and its associated factors among healthcare workers fighting covid-19 in southern ethiopia. the findings of this study are timely and would help the local program planners and policymakers to plan appropriate interventions at the early stage to prevent a detrimental psychological outcome of hcws. institution-based cross-sectional study was conducted among health workers working in gamo, gofa, konso, and south omo zones of southern ethiopia from 20, may to 20, june 2020. there are a total of two general and 10 primary hospitals, and 134 health centers in the four zones. there are 4820 health professionals providing health services in the zones. all health care workers working in four zones during the data collection period were included in the study. a single population proportion formula ((zα/ 2 ) pq/d 2 ) was used to estimate the sample size required for the study. the sample size calculation assumed the proportion (p), the estimated level of anxiety among hcws was estimated to be 50% because there is no prior study finding in ethiopia, 95% confidence level, margin of error of 5%, and a design effect of 2 which gave the sample size of 768. in consideration of a 10% non-response rate, the final sample size was 845 hcws. mathematically, it is calculated as follows: z= the standard score corresponding 95% confidence interval (1.96) p= level of anxiety among hcws, it was estimated to be 50% d= margin of error, 5% by considering a design effect of 2 because we used a multi-stage sampling technique (384 *2=768). then, we considered a 10% non-response rate, the final sample size used for this study was 768 + 77= 845. the study participants were selected using a multistage sampling technique. first, 20% of health institutions were selected using a simple random sampling technique (computer-generated random numbers) after allocating a proportion to each zone based on the size of health institutions. then, the sample size was proportionally allocated to the health institutes based on the size of health care workers. lists of active health care workers were taken from each selected health institute. finally, a simple random sampling technique (computergenerated random number) was implemented to recruit the health professionals in each selected health institute. a pretested and structured interviewer-administered questionnaire was used to collect data. the tools were developed by reviewing different works of literature and the world health organization (who) guidelines. the survey questionnaire included socio-demographic characteristics, medical history, alcohol use, physical exercise, and miscellaneous psychosocial questions. generalized anxiety disorder scale (gad-7) was used to assess the level of anxiety among health professionals. 19 it is a 7-item questionnaire developed to screen patients for anxiety and rate the severity of anxiety. each item is rated on a 4-point likert-scale ranging from 0 (not at all) to 3 (nearly every day) on the symptoms in the previous 2 weeks. the total score of gad-7 ranged from 0 to 21, with increasing scores indicated more severe functional impairments as a result of anxiety. for the purpose of this study, the score of anxiety assessing questions was calculated for each respondent then the overall score was computed and the levels of anxiety were classified into none to minimal, mild, moderate, and severe. scores represent 0-5 none to minimal, 6-10 mild, 11-15 moderate, and 15-21 severe anxiety. during data collection, a reliability analysis was done and the result showed a good score of internal consistency between the items (cronbach's alpha = 0.807). language experts translated the questionnaire from english to amharic and back to english to ensure consistency in meaning. a pretest was conducted on an unselected health institute by taking 5% of the total sample size. after we made appropriate corrections, the revised version of the questionnaire was used for final data collection. twelve trained public health professionals participated in the data collection. we used kobo collect survey tool to collect data. kobo collect survey tool is mobile applications that allow for the collection of data using mobile devices, analysis of data, and storage of data -either online or offline. data were collected using face-to-face data collection technique. all who recommended covid-19 protective measures were applied during the data collection period. data collectors and supervisors were provided with intensive training on the techniques of data collection and components of the instrument. before the commencement of the data collection, a pretest was conducted. a standard tool, which was developed by experts, was used to collect the information. the kobo collect survey tool that was very important to control the quality of data was used to collect data by using tablets. the authors and supervisors critically checked the data for completeness before being uploaded to the kobo collect cloud server. the collected data were downloaded from the kobo collect. it was then edited and cleaned for inconsistencies, missing values using excel, and then exported to spss version 25 (spss inc., chicago, il, usa) for further analysis. descriptive statistics were computed and summarized in tables, figures, and text with frequencies, mean, or standard deviations where appropriate. the association between the level of generalized anxiety disorder and its independent variables was examined by ordinal logistic regression. the ordinal logistic regression model was used because the level of anxiety was determined by using ordinal data (none to minimal, mild, moderate, and severe). the proportional odds model (pom) was fitted to identify factors associated with the level of generalized anxiety disorder. the necessary assumptions for pom were checked using parallel line tests. the psychology research and behavior management 2020:13 submit your manuscript | www.dovepress.com dovepress chi-squared test (χ2) for the proportional odds assumption was calculated to see whether the model assumptions were violated or not. the pearson χ2 goodness-of-fit test showed that the observed data were consistent with the fitted model; the deviance test (χ2=920.875, p =0.622) was non-significant. additionally, the appropriateness of the pom was calculated by the parallel line test, and it showed that the general model did not significantly differ from the fitted pom (p= 0.092), this indicated that the model fit the data well. furthermore, the χ2test of parallelism showed that the odds ratios were constant across all cutoff points of anxiety level for the final model at a 5% level of significance. bivariable analyses were performed between the dependent and independent variables. all variables with a p -value <0.25 in the bivariable analysis were fitted into the multivariable pom to control for confounding effects. an adjusted proportional odds ratio with a 95% ci was used to calculate the strength of the statistical association between the independent and dependent variables. ethical approval and clearance were obtained from arba minch university institutional research ethics review board, college of medicine and health sciences with reference number (irb/406/12). a letter of cooperation was obtained from the zonal health department and health institutes of the respective zones. the purpose of the study was explained and informed written consent was taken from each health care worker. to ensure confidentiality, their names, and other personal identifiers were not registered in the survey tool. besides, this study was conducted in accordance with the declaration of helsinki, and all ethical and professional considerations were followed throughout the study to keep participants' data strictly confidential. the data were collected from 798 study participants with a 94.2% response rate. out of the total respondents, 482 (60.4%) were male. the mean age (± sd) of the participants was 29.29 years (± 5.69) years. the majority of the participants were town residents (88.3%) and more than half of the participants were protestant religion followers (52.3). among the participants' health workers, 356 (44.6%) were clinical nurses and 363 (45.5%) were diploma holders (table 1) . among the respondents, 85% of them reported no adequate personal protective equipment in their health institute. the majority of the participants (96%) had access to media. of respondents, 96 (12%) had no confidence in coping with stress-related with covid-19, 682 (85.5%) had a feeling of susceptibility, and 633 (79.3%) had covid-19 related worries. among the participants, 630 (78.9%) believed that the suggested prevention and control practices can contain the pandemic (table 2) . among health care workers who participated in this study, 31.0%, 51.2%, 16.2% and 1.6% of them believed the community members were responding to the prevention practice of covid-19, not at all, somewhat, moderately, and to the great extent, respectively. more than two-thirds (72.2%) of hcws felt valued by their families. the data revealed that from the participant health care workers, 27.9%, 51.4%, 17.7% and 3.0% of them agreed the government is supporting the prevention and control of covid-19, not at all, somewhat, moderately, and to the great extent, respectively. the prevalence of mild and moderate anxiety disorder among hcws was 29.3% and 6.3%, respectively. there was no severe stage of anxiety observed during the data collection period (figure 1 ). in ordinal logistic regression analysis, variables such as contact with confirmed or suspected cases, covid-19 updates, confidence in coping with stresses, covid-19related worries, feel overwhelmed by the demands of everyday life, and feeling cannot make it were statistically significantly associated with an anxiety disorder. the risk of being in the higher order of anxiety was almost two times (apor =1.97; 95% ci: 1.239, 3.132) higher among health professionals who had contact with confirmed or suspected covid-19 cases compared to who had no submit your manuscript | www.dovepress.com psychology research and behavior management 2020:13 contact. likewise, health care professionals who had no covid-19 update were almost 5 times (apor=4.81, 95% ci=2.957, 7.842) more likely to develop a higher order of anxiety than those hcws who had an update. similarly, hcws who were somewhat confident in coping with stress were 2.7 times (apor=2.74, 95% ci=1.633, 4.606) more likely to develop a higher order of anxiety disorder than their counterparts. regarding covid-19 related worries, the odds of health care workers who had covid-19 related worries were 1.85 times (apor=1.85, 95% ci=1.120,3.056) more likely to experience higher order of anxiety than who did not worry. the odds of health care workers who had not felt overwhelmed by the demands of everyday life were 48% (apor=0.52, 95% ci=0.370,0.733) less likely to develop a higher order of anxiety than who was feeling overwhelmed. similarly, the odds of health care professionals who did not feel that they cannot make it were also 56% (apor=0.44, 95% ci=0.308, 0.626) less likely to experience higher order of anxiety than who felt they can make it (table 3 ). the study examined the prevalence of anxiety among health care workers and identified risk factors for increased anxiety. the finding of this study revealed that 29.3% and 6.3% of hcws suffered from mild and moderate anxiety disorder, respectively. a study from china reported that 44.6% of the hcws had symptoms of anxiety. 20 a related study conducted in turkey indicated that 51.6% of respondents had anxiety-related symptoms. of this, 16.3, 13.1%, 10.6%, and 11.5%, of hcws had mild, moderate, severe, and extremely severe anxiety symptoms, respectively. 21 another recent meta-analysis of studies reported the prevalence rate of the anxiety of hcws during covid-19 was ranging between 22.6%-36.3%. 22 pockets of studies from different corners of the world had been reported the prevalence of anxiety among hcws with a range of 11.350% 20,23-25 and finding of the present study was within this reported range. the finding of the current study showed that the majority of the hcws experienced mild symptoms of anxiety, while moderate and severe symptoms were less common among the participants. in our view the reported figure is huge since the study was conducted at the early stage of the pandemic in ethiopia; this alarms the need for early detection and the importance of picking up and effectively treating the milder clinical symptoms of anxiety dovepress before they evolve to more complex psychological disorders. furthermore, a lower moderate and severe level of anxiety might be associated with the lower report of confirmed cases due to limited testing capacity during the study period in comparison with other countries. there was also a lower report of confirmed cases in the study area. a study from china which was the epicenter of covid-19 showed that working outside the epicenter was associated with a lower risk of psychological symptoms than working in the epicenter even in the same country. 20 however, mild anxiety symptoms were higher among hcws in the study area. this high level of anxiety among the hcws in our study area could be attributed to fear of transmission of the disease to their family, no updates on covid-19-related issues especially hcws working in a rural area with no mobile network and internet connection, lack of specific drugs treating covid-19 patients, an increasing number of suspected and confirmed cases and inadequate personal protective gears. eighty-five percent of the participants perceived that personal protective equipment was inadequate in their health institutions. the difference in the prevalence of anxiety in different parts of the world could be attributed to variations in the health system characteristics, the culture of patient care, technologies, availability of ppe, and the tool used to assess anxiety and heterogeneity in cut off points. in the present study, we used the standard and validated tool developed for measuring generalized anxiety disorder after we checked its validity and reliability in our context. 19 authorities at different hierarchies should assess the hazards to which their health care workers are exposed; evaluate the risk of exposure; and select, implement, and ensure workers use controls to prevent exposure to the virus. occupational health surveillance has paramount importance to enhance the wellbeing of hcws. such type of study is helpful for different stakeholders to monitor mental health issues to understand the mediating factors and inform evidence-based interventions in a timely fashion. 26, 27 our study further indicated that health professionals who had contact with confirmed or suspected covid-19 cases were two times more likely to develop a higher order of anxiety than those who had no contact. the finding of this study was consistent with the studies conducted in china, 24,25 the score of anxiety increases among health care workers having direct contact with suspected and confirmed cases. this can be reasoned out that contact with suspected or confirmed cases increases the risk of transmission and exposure. the health workers working in low resource settings (weak health system, low economic status, and poor technology) like ethiopia may limit their ability to follow the recommended measures; these and other factors exacerbate the fear of hcws. although the ethiopian government and people presented recognition for hcws for their dedication in fighting covid-19which could make health workers feel honored and proud to participate in this difficult assignment -the local and national authorities should also focus on implementing measures targeting the psychological well-being of hcws. likewise, health care professionals who had no covid-19 update were almost 5 times more likely to develop a higher order of anxiety than those health care professionals who had an update. this can be explained by hcws getting information on the route of transmission, the availability and effectiveness of medicines/vaccines, experience in handling covid-19 patient, the number of infected cases and locations, and advice on prevention of the covid-19 increase the confidence of hcws otherwise working in an uncertain environment without up to date information might worsen anxiety. this finding was also in agreement with the study conducted in china. 29 the odds of health care professionals who had covid-19 related worry were more likely to experience higher order of anxiety than those health care workers who did not worry. this might be justified as health care workers are working in a highly risky environment so that increases the probability of being infected so that they might worry about transmitting the infection to their families and loved ones, separating with their children, and being stigmatized. the finding was also supported by other studies; 28,29 respondents were very worried or somewhat worried about other family members getting covid-19. furthermore, personal protective equipment, such as surgical masks face mask, eye goggles, protective clothing, gloves, and sanitizers, were severely deficient during the early stages of the outbreak in ethiopia which might exacerbate worries of health care workers. overwhelmed by daily activities and cannot make it were also significantly associated with developing higher order of anxiety among hcws. this might be due to work overload, inner conflict about competing needs and demands of hcws, stigma, and fear of being removed from their duties during a crisis heighten anxiety. this study has some limitations which have to be taken into consideration while interpreting the findings. as being crosssectional in the design, it does not confirm the definitive cause and effect relationship. we were unable to differentiate the preexisting anxiety from the new cases of anxiety. the other limitation of the study might be social desirability bias but we tried to minimize it by reminding participants about confidentiality and anonymity during data collection. however, the current study had strength; to the best of our knowledge, this is the first study assessed the prevalence of anxiety among hcws during covid-19 in ethiopia, we used a strong method of analysis (ordinal logistic regression), a validated and standardized tool with an appropriate cut off points to the study revealed that the prevalence of anxiety disorder among health care workers was high in the study area. covid-19 updates, contact with confirmed or suspected cases, confidence in coping with stresses, covid-19 related worry, feel overwhelmed by the demands of everyday life, and feeling cannot make it were significant factors associated with the higher order of anxiety. the findings of the current study suggest immediate psychological intervention for health care workers in the study area is vital. therefore, proactive measures should be taken by the stakeholders at different hierarchies to promote the psychological wellbeing of hcws in order to control the impact of the pandemic on the hcws, and containing the pandemic. tribute to healthcare operators threatened by covid-19 pandemic adjustment process during epidemics of covid-19 and mental health the covid-19 pandemic, personal reflections on editorial responsibility national institute for health and care excellence epidemiology of anxiety disorders in the australian general population: findings of the 2007 australian national survey of mental health and wellbeing mental health of medical workers in pakistan during the pandemic covid-19 outbreak depression after exposure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers mental distress among liberian medical staff working at the china ebola treatment unit: a cross sectional study. health qual life outcomes risk perception and impact of severe acute respiratory syndrome (sars) on work and personal lives of healthcare workers in singapore what can we learn? protecting the mental health of healthcare workers during the covid-19 emergency mental symptoms in different health professionals during the sars attack: a follow-up study the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perception, and altruistic acceptance of risk the prevalence and influencing factors in anxiety in medical workers fighting covid-19 in china: a cross-sectional survey mental health and psychosocial problems of medical health workers during the covid-19 epidemic in china psychological impact of the covid-19 pandemic on health care workers in singapore impact of severe acute respiratory syndrome on anxiety levels of front-line health care workers ethiopian monitor a brief measure for assessing generalized anxiety disorder factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019 depression, anxiety, stress levels of physicians and associated factors in covid-19 pandemics prevalence of depression, anxiety, and insomnia among healthcare workers during the covid-19 pandemic: a systematic review and meta-analysis prevalence and influencing factors of anxiety and depression symptoms in the first-line medical staff fighting against covid-19 in gansu a multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid-19 outbreak psychological impact of the covid-19 pandemic on health care workers in singapore covid-19 infection in italy: an occupational injury the crucial role of occupational health surveillance for health-care workers during the covid-19 pandemic. workplace health saf immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china covid-19-related stress, anxiety and depression during the pandemic in a large population enriched for healthcare providers the authors are grateful for the data collectors, the study participants, and supervisors for their co-operation during data collection. our thanks also goes to arba minch university for funding and providing ethical clearance. all authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published; and agree to be accountable for all aspects of the work. the authors report no conflicts of interest in this work. psychology research and behavior management is an international, peer-reviewed, open access journal focusing on the science of psychology and its application in behavior management to develop improved outcomes in the clinical, educational, sports and business arenas. specific topics covered in the journal include: neuroscience, memory and decision making; behavior modification and management; clinical applications; business and sports performance management; social and developmental studies; animal studies. the manuscript management system is completely online and includes a very quick and fair peer-review system, which is all easy to use. visit http://www. dovepress.com/testimonials.php to read real quotes from published authors. key: cord-299567-tlnvqah3 authors: irfan, m.; shahudin, f.; hooper, v.; akram, w.; ghani, r. title: the psychological impact of coronavirus on university students and its socio-economic determinants in malaysia date: 2020-10-30 journal: nan doi: 10.1101/2020.10.27.20220723 sha: doc_id: 299567 cord_uid: tlnvqah3 this article examines the impact of coronavirus disease 2019 (covid-19) upon university students anxiety level and finds the factors associated with the anxiety disorder in malaysia. we collected data from 958 students from 16 different universities using an originally designed questionnaire. the generalized anxiety disorder scale 7-item (gad-7) was used to estimate the anxiety. we find that 12.3% students were normal, whereas 30.5% were experiencing mild, 31.1% moderate,and 26.1% severe anxiety. surprisingly, only 37.2% of students were aware of mental health support which was provided by their universities. moreover,it was found that gender as male (odds ratio (or= 0.798, 95% confidence interval (ci)= 0.61-1.04)) and having internet access (or = 0.44, 95% ci= 0.24-0.80) were alleviating factors for the anxiety. whereas, age above than 20 years (or= 1.30, 95% ci= 0.96-1.75), ethnicity chinese (or=1.72, 95% ci= 0.95-3.1), any other disease (or=2.0, 95% ci=1.44-2.79), decreased family income (or=1.71, 95% ci=1.34-2.17), more time spent on watching covid-19 related news (or=1.52, 95% ci=1.17-1.97), and infected relative or friends (or=1.62, 95% ci=1.06-2.50) were risk factors for anxiety among students. we suggest that the government of malaysia should monitor the mental health of the university students more closely and universities should open online mental health support clinics to avoid the adverse impacts of the anxiety disorder. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 30, 2020. ; https://doi.org/10.1101/2020. 10 .27.20220723 doi: medrxiv preprint coronavirus disease 2019 continues to devastate almost every country in the world. as of 24 th october 2020, total deaths have reached 1.2 million and infections 42. 6 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 30, 2020. ; https://doi.org/10.1101/2020. 10.27.20220723 doi: medrxiv preprint 3 the impact of the virus is different in various countries mainly because of the environment, herd immunity, health system, government strategies, and public response. for example, san marino has maximum per million fatalities (1,237) followed by peru, belgium, and andorra 2 . to avoid the distressing impact of the covid-19, every country has adopted numerous health, fiscal, and public policies. so far, malaysia has made tremendous progress in controlling the impact of covid-19. as a result of the better policies and public responses, as of 11 th september 2020, malaysia has a total 9,628 confirmed cases out of which 9,167 recovered and 128 died (1.33%). the first case of covid-19 in malaysia was confirmed on 25 th january 2020 [1] but the cases continued to rise steadily until the end of the february 2020. after the 14 th of march the sudden rise in the covid-19 cases were noted which was believed to be associated with a religious gathering in kuala lumpur (capital city of malaysia) [2] . approximately, 16,000 people attended that gathering, eventually leading to a rise in the total cases that were observed during the next two months. the government of malaysia immediately implemented the movement control order (mco) commencing from 18 th march 2020 to control the spread of the virus [3] , which was subsequently relaxed in august 2020. during the period of the mco gatherings at all places were prohibited including religious services and universities. this was the time when almost all the universities in malaysia shifted their mode of teaching from physical to virtual. the sudden change in the mode of teaching due to the potential risk of death caused by covid-19, isolation, and lockdown have increased the anxiety level and created extreme stress to the general public [4] and students alike [5] the abnormal stress and depression amongst students not only affect their performance but also is associated with heightened self-injury and suicidal attempts [6] . therefore, it is immensely important to monitor the mental health of the students and assess the risks coupled with preventive factors of the anxiety and associated mental health issues. we selected malaysia as a case country because of the better possibility of the data collection. secondly, to date, most of the studies have explored the impact of covid-19 on students in china, paramedical staff, patients, and even on the general public but the university students in malaysia are overlooked. hence, this paper examines the impact ofcovid-19 on students' anxiety in malaysia. as well as it finds the socioeconomic factors which are associated with students' anxiety. the rest of the paper is organized as follows: section 1.1 reviews the earlier 2 https://www.worldometers.info/coronavirus / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october 30, 2020. ; https://doi.org/10.1101/2020.10.27.20220723 doi: medrxiv preprint 4 studies, section 2 explains the data, variables, and methods, section 3 discusses the results, and section 4 concludes the paper. a handful of studies attempted to examine the association between covid-19 and mental health. for instance, [4] investigated the psychological symptoms of 1,060 chinese citizens during covid-19 using a symptoms checklist of 90 via an online questionnaire. they found more than 70% of the total sample had a moderate and higher level of an obsessive compulsion disorder, interpersonal sensitivity, phobic anxiety, and psychoticism. interestingly, people older than 50 years had relatively more symptoms than young people. moreover, the symptoms were higher among people who had an education level of undergraduate and below, been divorced, or widowed. likewise, [7] in chinese jiangsu province, measured the impact of covid-19 on the anxiety level amongst 534 pediatric medical staff. using a self-rating anxiety scale based upon the pittsburgh sleep quality index, they found that the prevalence of anxiety was 14.0% amongst the medical staff. they applied stepwise multiple linear regressions to examine the association between anxiety and other socio-economic factors. it was discovered that having a physical condition and concerns relating to the epidemic were positively associated with anxiety levels. whereas, positional title, better living style, and education were negatively associated with anxiety level. similarly, another study conducted by [8] found that there was significantly higher psychological distress amongst medical staff deployed to hubei province [12] examined the psychological impact of the covid-19 on college students. using cluster sampling, they collected data from 7,143 students from changzhi medical college china. using gad-7, they found that 21.3% of respondents were experiencing mild, 2.7% moderate, and 0.9% severe anxiety. furthermore, they applied the ordered logit model and explored that living in urban areas, living with parents, having a steady family income were protective factors against anxiety. our study 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 30, 2020. ; https://doi.org/10.1101/2020.10.27.20220723 doi: medrxiv preprint 5 uses the same methods for measuring the anxiety factors associated with this mental health issue. however, our study covers around 16 universities, which produces more generalizable and comprehensive estimates, because of the heterogeneity amongst the sample. moreover, kaparounaki et al. (2020) [13] examined the impact of covid-19 on the mental health of university students in greece. they collected the data from 1,000 university students and found that 42.5% of the total sample population had anxiety and 74.3% depression. using similar data, patsali et al., (2020) found that depression was present in 12.43% and severe distress was present in 13.46% of the sample population. of concern, they noticed a 2.59% increase in suicidal thoughts. in malaysia, we could only find one study by sundarasen et al., (2020) [14] that was conducted in a similar vein. their study was the closest to us in terms of our research objectives. however, they used zung's self-rating anxiety scale (sas) to estimate the anxiety level. quite surprisingly, they found only 8% of students were experiencing mild to moderate and moderate to severe anxiety, which is substantially different from the findings of other studies, hence this requires further investigation. the basic reason for an extremely low number could be using zung's self-rating anxiety scale. the anxiety scale has been criticized by earlier studies [15] [16] [17] for producing unreliable results. thus, our study covers a more comprehensive base of 16 universities and applies advanced methods to estimates the anxiety amongst students. we further explored the factors which influence the anxiety level. we created a google form which consists of 45 questions (including gad-7) for collecting data and sent the link through email, whatsapp, zoom, microsoft teams, google meetings, wechat, and other social media platforms. we collected demographic, social, and economic information from the respondents such as living area, age, gender, education, current semester, number of friends, family income, and so on. whereas, the question related to anxiety was taken from gad-7. in total, 958 students from 16 different universities participated in the survey. the respondents were requested to provide their consent to use their information for research purposes only. the participation was voluntary and respondents had the option to exit the survey at any point. data were collected in july 2020 when the mode of teaching in most of the universities was entirely virtual learning. 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 30, 2020. ; https://doi.org/10.1101/2020.10.27.20220723 doi: medrxiv preprint 6 the dependent variable "anxiety level" was constructed using gad-7 questionnaire. it is gleaned from the practical self-reporting questionnaire which consisted of 7 items such as feeling nervous, not able to stop worrying, worrying to much about different things, trouble relaxing, being restless, being easily annoyed, and feeling afraid [18] . the gad-7 is widely used in the literature and its validity has been tested in numerous studies such as löwe et al., (2008), barthel et al., (2014) , and seo and park, (2015) [19] [20] [21] . depending upon the response of the students, four categories of anxiety were created such as 1 means no anxiety, 2 = mild anxiety, 3 = moderate anxiety, and 4 = severe anxiety. hence, the variable has an order from 1 to 4, where 1 means no anxiety and 4 means severe anxiety. after estimating the anxiety level among students, we applied ordered logit modeling to examine the impact of various socio-economic and demographic variables. the list of our variables of interest along with frequencies and percentages is given in the table 1. 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 30, 2020. the ordered logit model is suitable when the proportional odds assumption satisfies and the coefficients are usually estimated by using the maximum likelihood method. the model has been used in recent studies by [12, 14] to estimate the odds ratios. in our case, we had an ordinal dependent variable "anxiety level" and our objective was to predict the odds ratios. the odds ratios represent the constant effect of an independent variable on the likelihood that one outcome (dependent variable) will occur. we had four levels of our dependent variable such as no anxiety, mild anxiety, moderate anxiety, and severe anxiety. the model can be characterized as follows, * = ∑ + = + (1) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 30, 2020. ; https://doi.org/10.1101/2020.10.27.20220723 doi: medrxiv preprint 8 where * is our unobserved dependent variable and represents the list of independent variables, is the error term, and shows the coefficients which we have estimated. please note that there is no intercept here it means we have estimated m-1 odds ratios that the dependent variable takes on with respect to a particular value identified in equation 1. table 1 shows the frequencies of anxiety levels among students. surprisingly, almost 57% of our sampled students were experiencing moderate or severe anxiety during covid-19, whereas, almost 62% of the students did not know whether their institutions were providing mental health support. perhaps, universities might not have anticipated the sudden surge in anxiety levels, however, this might have serious repercussions on learning experiences. the results of the ordered logit model are presented in table 3 . we have only elaborated the significant results where p-value was less than 0.10. we found that the odds of being at the higherlevel of anxiety decreases (or=0.798 95% ci = 0.61 to1.04) if the students were male. in other words, male students were less likely to develop a higher level of anxiety in comparison with female students. perhaps, female students are more sensitive to the covid-19 situation than males. furthermore, the odds of being at the higher-level anxiety increases by 1.3 times (95%ci = 0.96 to 1.75) if the students were above 20 years old in comparison to those whose age was below 20 years. perhaps older students take the impact of coronavirus more seriously which may lead to an upsurge in anxiety level. interestingly, the odds of being at a higher level of anxiety increases by 1.7 times (95% ci = 0.95 to 3.09) if the students were of chinese ethnicity in comparison to other ethnicities (indian, bengali, arabian, and indonesian). moreover, having internet access helps to reduce anxiety amongst students. we found that the odds of being at a higher level of anxiety decreases (or = 0.45, 95% c. i = 0.25 to 0.80) if students have internet access. perhaps, the students can have more entertainment options at home which may lead to reduce anxiety. secondly, due to the lockdown or mco outdoor sports and other activities were banned, hence, in this situation having internet access could be a significant factor to control anxiety level. most importantly, students during the mco period were taking online classes, therefore, having an internet connection helps them to concentrate on the study, which means they would be thinking less of covid-19. 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 30, 2020. ; https://doi.org/10.1101/2020. 10.27.20220723 doi: medrxiv preprint undoubtedly, covid-19 has affected economic activities adversely and because of the lockdown which has led to personal income reducing significantly. this might have a severe impact on the welfare and the anxiety level of individuals. we found that the odds of being at the higher-level of anxiety increase by 1.7 times (95% c.i = 1.34 to 2.17) if students' family income diminishes because of the coronavirus. almost 52% of the students reported that their family income has reduced because of the low economic activities and lockdown which was the result of covid-19. furthermore, having any other disease may increase the level of anxiety among students. our study found that the odds of being at the higher level of anxiety increase by 2.0 times (95% c.i = 1.44 to 2.79) if students have any other pre-existing disease. perhaps pre-existing diseases have a cumulative effect on fear and lead to a higher level of anxiety. likewise, spending more than 30 minutes weekly on watching the coronavirus related news can significantly increase the anxiety level among students (or=1.51, 95% ci = 1.2 to 1.97). additionally, having an infected friend or relative can significantly increase the anxiety level amongst students. we found that the odds of being at the higher level of anxiety increases by 1.62 times (95% c.i = 1.06 to 2.46) if students' friends or relatives were infected by covid-19. the likelihood of having anxiety decreases if the students live with their parents and reside in urban areas. in addition, as the number of close friends increases, anxiety decreases. however, these results were not significant. perhaps, future larger sample size studies may explore some more interesting exploratory discoveries in our study that may lead to more definite and significant findings. secondly, the data were collected in july 2020, when the curve of the covid-19 in malaysia was getting flatter. perhaps, data collection in some other time periods may produce slightly different results. 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 30, 2020. ; https://doi.org/10.1101/2020.10.27.20220723 doi: medrxiv preprint the covid-19 outbreak continues to create chaos in almost every country as of september 11 th 2020, no vaccination against the virus is available in the market. however, several scientific groups are in the process of developing a potential vaccine. in response to controlling the virus, every country has taken various steps such as lockdowns, quarantines, social distancing, isolations, and mcos. the fear of death due to covid-19 and government measures to control the spread of the virus have affected the mental health of citizens and students in particular. the psychological impact of covid-19 in malaysian students is a relatively unexplored phenomenon. we explored 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 30, 2020. ; https://doi.org/10.1101/2020.10.27.20220723 doi: medrxiv preprint the anxiety amongst students in malaysia and found that around 57% of the students were experiencing moderate to severe anxiety. surprisingly, only 37% of students were aware of mental health support services which are provided by their institutions. additionally, gender as male and internet access were a protective factor against anxiety, despite the potential for the internet to increase anxiety through constant worrying news reports. whereas, age above 20 years, ethnicity as chinese, decreased family income, a pre-existing disease, spending more than 30 minutes weekly on watching or reading covid-19 related news, and having an infected family or friends were viewed as the major risk factors for anxiety. treatment of anxiety involves various interventions including the medication, counselling, and therapy, the combination of all of these usually being more effective. we suggest higher education institutions should assist universities to open mental health support (both psychiatric and psychology based) clinics on every campus, with online access. these services should be provided on both an informal and formal basis as well because those students who are unable to visit the clinic physically can get mental support on call or chat. it is also important to regularly monitor the mental health condition of the students. the financial packages or support can help families to maintain their income which eventually lowers the anxiety level. it can also lead to greater economic productivity in lockdowns. hence, we suggest the government should also consider providing financial support to the families working from home during lockdowns and higher stringency regimes. moreover, sports clubs and student societies can also reduce anxiety amongst students by operating within the context of social distancing. these concerns should be addressed by the ministries of education and quality control. our policy suggestions can lower the anxiety amongst students and can help the policy setters in formulating the adequate policies. our results are likely to be of interest to education policy setters around the globe as the majority of students around the world have experienced very similar issues during covid-19 lockdowns as teaching has been online, and so they confront common issues. we hereby declare that; the paper reflects the authors' own research and analysis in a truthful and complete manner. the results are appropriately placed in the context of prior and existing research. in addition, no animal or human were harmed, no blood samples were collected, no clinical trials 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october 30, 2020. ; https://doi.org/10.1101/2020.10.27.20220723 doi: medrxiv preprint were carried out, identity of the respondents kept confidential, and prior consent from the respondents were taken. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors authors have no conflicts of interest to disclose 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october 30, 2020. ; https://doi.org/10.1101/2020.10.27.20220723 doi: medrxiv preprint 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october 30, 2020. ; https://doi.org/10.1101/2020.10.27.20220723 doi: medrxiv preprint 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 view publication stats view publication stats . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted october 30, 2020. ; https://doi.org/10.1101/2020.10.27.20220723 doi: medrxiv preprint investigation of three clusters of covid-19 in singapore: implications for surveillance and response measures movement control as an effective measure against covid-19 spread in malaysia: an overview psychosocial support for healthcare front liners during covid-19 pandemic in malaysia psychological symptoms of ordinary chinese citizens based on scl-90 during the level i emergency response to covid-19 the psychological impact of the covid-19 epidemic on college students in china university students' changes in mental health status and determinants of behavior during the covid-19 lockdown in greece anxiety in chinese pediatric medical staff during the outbreak of coronavirus disease 2019: a cross-sectional study covid-19) epidemic on medical staff in different posts in china: a multicenter study the effect of age, gender, income, work, and physical activity on mental health during coronavirus disease (covid-19) lockdown in austria psychological impact during an epidemic: data from italy's first outbreak of covid-19 generalized anxiety disorder, depressive symptoms and sleep quality during covid-19 outbreak in china: a web-based cross-sectional survey the psychological impact of the covid-19 epidemic on college students in china university students' mental health amidst the covid-19 quarantine in greece psychological impact of covid-19 and lockdown among university students in malaysia: implications and policy recommendations effects of affective-semantic mode of item presentation in balanced self-report scales: biased construct validity of the zung selfrating depression scale comparison of hospital anxiety and depression scale (hads) and zung self-rating anxiety/depression scale (sas/sds) in evaluating anxiety and depression in patients with psoriatic arthritis a brief measure for assessing generalized anxiety disorder: the gad-7 validation and standardization of the generalized anxiety disorder screener (gad-7) in the general population psychometric properties of the 7-item generalized anxiety disorder scale in antepartum women from ghana and côte d'ivoire validation of the generalized anxiety disorder-7 (gad-7) and gad-2 in patients with migraine key: cord-355776-f8u66hbt authors: ni, zhao; lebowitz, eli r.; zou, zhijie; wang, honghong; liu, huaping; shrestha, roman; zhang, qing; hu, jianwei; yang, shuying; xu, lei; wu, jianjun; altice, frederick l. title: response to the covid-19 outbreak in urban settings in china date: 2020-09-09 journal: res sq doi: 10.21203/rs.3.rs-71833/v1 sha: doc_id: 355776 cord_uid: f8u66hbt the covid-19 outbreak in china was devastating, and spread throughout the country before being contained. stringent physical distancing recommendations and shelter-in-place were first introduced in the hardest-hit provinces, and by march, these recommendations were uniform throughout the country. in the presence of an evolving and deadly pandemic, we sought to investigate the impact of this pandemic on individual well-being and prevention practices among chinese urban residents. from march 2-11, 2020, 4,607 individuals were recruited from 11 provinces with varying numbers of covid-19 casers using the social networking app wechat to complete a brief, anonymous, online survey. the analytical sample was restricted to 2,551 urban residents. standardized scales measured generalized anxiety disorder (gad), the primary outcome. multiple logistic regression was conducted to identify correlates of gad alongside assessment of community practices in response to the covid-19 pandemic. we found that during the covid-19 pandemic, recommended public health practices significantly (p <0.001) increased, including wearing facial mask, practicing physical distancing, handwashing, decreased public spitting, and going outside in urban communities. overall, 40.3% of participants met screening criteria for gad and 49.3%, 62.6%, and 55.4% reported that their work, social life, and family life were interrupted by anxious feelings, respectively. independent correlates of having anxiety symptoms included being a healthcare provider (aor=1.58, p <0.01), living in regions with a higher density of covid-19 cases (aor=2.13, p <0.01), having completed college (aor=1.38, p =0.03), meeting screening criteria for depression (aor=6.03, p <0.01) and poorer perceived health status (aor=1.54, p <0.01). covid-19 had a profound impact on the health of urban dwellers throughout china. not only did they markedly increase their selfand community-protective behaviors, but they also experienced high levels of anxiety associated with a heightened vulnerability like depression, having poor perceived health, and the potential of increased exposure to covid-19 such as living closer to the epicenter of the pandemic. the novel coronavirus disease 2019 (covid-19) pandemic rst rapidly spread throughout china, and by august 19 th , 2020, it had manifested in 188 countries with 22,244,179 con rmed cases and 783,525 deaths worldwide. 1 in the absence of effective vaccines or treatments, public health authorities have relied upon sheltering in place (self-quarantine at home), physical distancing in public settings, hand washing and wearing facial masks to prevent further spread. 2, 3 without fully understanding its transmission, risk of progression, and widespread death from covid-19, panic and even hysteria were common. 4 the world health organization made public the covid-19 outbreak in january 2020, 5 and observed that the outbreaks were more severe in urban settings with a higher density of people. 6 consequently, chinese residents increasingly complied with recommended containment measures that are necessary under this time of crisis, but those measures could disrupt their work and social and family life. also, during the pandemic, many urban dwellers remained relatively segregated within their neighborhoods, and this negatively impacted their psychological well-being. 7, 8 anxiety symptoms among urban dwellers dealing with a volatile covid-19 pandemic, however, has not been broadly examined since it does not affect everyone equally. over the past 18 years, various settings have reacted to new infectious diseases epidemics like sars, mers, and ebola and, though none of these developed pandemic proportions, understanding factors that may undermine the health of the community are important for future public health disaster planning efforts. we, therefore, conducted a nationwide online survey of people in china to identify those factors associated with anxiety from covid-19 and focused only on urban dwellers here, since they experienced covid-19 differently than their nonurban counterparts. we conducted baseline, online survey with 4,607 participants living in china; two additional waves are underway. participants inclusion criteria included: 1) ≥18 years old; 2) living in mainland china; 3) able to read chinese; and 4) had access to wechat (the largest social networking app in china). all recruited participants were asked to complete a baseline survey over ten days from march 2-11, 2020 . a total of 4,607 individuals from 11 provinces, with the varied impact of the covid-19 pandemic, completed the online survey. the analytical sample was restricted to 2,551 urban residents who completed the enrollment survey. in this paper, the time point of covid-19 outbreak refers to january 23 rd , 2020, when wuhan city was placed in quarantine. the study protocol was approved by the institutional review board of yale university and received ethical approval from wuhan university. in this study, we used a modi ed snowball recruitment strategy where 11 participants (seeds) were recruited one each from 11 representative provinces in china. eleven representative provinces were selected from mainland china based on two criteria: 1) being in one of mainland china's six socialeconomic regions as classi ed by the national bureau of statistics of china: north (beijing, tianjin, heibei, shanxi, inner mongolia), northeast (liaoning, jilin, heilongjiang), east (shanghai, jiangsu, zhejiang, anhui, fujian, jiangxi, shandong), central south (henan, huibei, hunan, guangdong, guangxi, hainai), southwest (chongqing, sichuan, guizhou, yunnan, tibet), and northwest (shaanxi, gansu, qinghai, ningxia, xinjiang); 9 and 2) covid-19 severity as was categorized by china national health commission 10 (diagnosed covid-19 cases≥10,000; 1,000-9,999; 100-999; ≤99) based on the percentage of provinces in each stratum in march 2020 ( figure 1 ). using these criteria, we selected the following 11 representative provinces: beijing, inner mongolia, heilongjiang, shandong, henan, hubei, hunan, guizhou, shaanxi, gansu, and xinjiang. seeds were recruited using convenience sampling method. to address the impact of the covid-19 pandemic, the survey was developed, and pilot tested using methods that have been described elsewhere. 11 in brief, standardized scales were used, and responses to covid-19 were created. after drafting candidate questions, ten experts in the eld took the survey and provided feedback to re ne the survey. the revised survey was then designed on questionnaire star (https://www.wjx.cn/), a professional platform for online surveys, 12 and a web link, and a qr code was generated. we then pilot-tested the survey with 32 individuals who accessed the survey from a weblink or qr code and sought feedback. using feedback, we nalized the electronic survey and applied the webbased sampling method to recruit participants after identifying the seed in each province. the selected 11 seed participants completed the survey and then distributed a yer that contained recruitment information, quick response (qr) code, and a link to the online survey among their social network. the distribution of the yer occurred through wechat moments ("peng you quan" in chinese) or their wechat groups ("wei xin qun" in chinese). interested individuals who clicked on the link were directed to an eligibility screener. each eligible participant voluntarily completed an online consent form by acknowledging that they understood the purpose, risks, and bene ts of the study prior to completing the survey. on average, participants took 12 minutes to complete the anonymous online survey. the questionnaire was available in both english and chinese languages and was translated and backtranslated to ensure culture meaning. 13 sociodemographic characteristics included age, sex, educational level, income, health, employment, and marital status. income was strati ed based on the relationship to the national levels. traveling history in the past 30 days included whether they had traveled after the covid-19 outbreak, and whether they were put in quarantine. living environment was based on with whom they lived, and the region where they lived, strati ed by the density of covid-19 cases, with hubei province being the highest. we also measured where participants accessed information pertaining to covid-19 and what measures that their communities had taken to control covid-19. participants' self-perceived health status were measured by the question "how is your current health status?" with a response of "very good", "good", "fair", "poor", and "very poor". these answers were dichotomized into "good" ("very good" + "good"), and "not good" ("fair" + "poor" + "very poor"). in addition, we assessed the frequency of the following health-related behaviors, before and after the covid-19 outbreak, which included wearing face masks, practicing physical distancing, washing hands, spitting, and showering. the questions related to each construct are included in table 2 . the primary outcome was the presence of anxiety symptoms severity, which was measured by the generalized anxiety disorder 7-item (gad-7) scale, which has good reliability, sensitivity, and speci city for measuring anxiety in chinese populations. 14 generalized anxiety disorder (gad) cut-offs for mild, moderate, and severe symptoms including scores of 5-9, 10-14, and >15, respectively. other screening for mental illness included assessment of obsessive-compulsive symptoms using the obsessive-compulsive inventory 15 and depression using the patient health questionnaire-2. 16 all data analyses were performed using sas 9.4 (sas institute, cary, north carolina, united states). data were presented using frequencies and means. chi-square test was used to compare the behaviors of wearing face masks and practicing physical distancing before and after the covid-19. student's t-test was used to examine differences in hand washing, spitting, going outside, and showering, before and after the outbreak. logistic regression was used to examine the association between potential explanatory variables and the presence of anxiety. anxiety was dichotomized for values >4, which is associated with the presence of anxiety symptoms. any variable signi cant at p<0.10 in bivariate analyses were then entered into the multivariate logistic regression model to determine the odds ratio and 95% con dence intervals for the nal model. an additional analysis (supplementary data) for moderate to severe anxiety symptoms (cut-off >9) was also conducted. most participants (table 1) were female (68.9%), in their 30s (31.3±11.9), completed a college degree (89.5%), and perceived themselves to be in good health status (74.8%). nearly 34% of the participants have an annual income of greater than ¥ 60,000 (12 times greater than the international poverty threshold; equivalent to 8,571 usd), and 16.0% of the participants were healthcare providers. nearly all (93.1%) participants were living with families and remained in one city during the 30 days prior to the study. participants were from regions with different density of covid-19 cases, 22.8% of them were from the epicenter -hubei province. nearly half of the participants were married (47.4%). most participants reported that they didn't travel (95.5%) after the covid-19 outbreak, and most communities (93.4%) had taken strict measures to control covid-19. overall, the top three commonly used preventative measures in chinese urban areas were: controlling the entry and exit of people by checking their body temperature, banning gatherings in the community, and cleaning and sanitizing communal spaces ( figure 2 ). the number of participants who wore face masks and practiced physical distancing, and the frequency of hand washing increased signi cantly after the covid-19 outbreak (p<0.001). the rate of spitting in public places and going outside of one's home decreased signi cantly (p<0.001; table 2 ). [ insert table 2 here] 3.3. correlates of having generalized anxiety disorder several independent correlates were associated with having mild, moderate, and severe anxiety symptoms, including poor perceived health status (aor=1.54, p<0.01), being a healthcare provider (aor=1.58, p<0.01), received a college degree or above (aor=1.38, p=0.03), living in hubei (aor=2.13, p<0.01), and meeting screening criteria for depression (aor=6.03, p<0.01; table 3 ). 3.4 correlates of moderate to severe generalized anxiety disorder as shown in table 4 in the supplementary appendix, poor self-perceived health status (aor=1.73, p<0.01), higher frequency of washing hands (aor=1.02, p=0.03), living in hubei (aor=2.85, p<0.01), and meeting screening criteria for depression (aor=24.20, p<0.01) were independently associated with moderate and severe anxiety symptoms. the unprecedented covid-19 pandemic has raised signi cant public health concerns and has an extended impact on the psychological well-being of society, especially in urban areas most profoundly impacted by the disease. the covid-19 epidemic unleashed a rapid and cataclysmic response by society, in which we report the profound protective response to the covid-19 outbreak. in response to government guidance and clear messaging, frequency of hand washing and physical distancing practices increased, while venturing outside in crowded urban spaces or spitting in public places decreased. though public spitting is unlawful in some chinese cities like beijing, 17 hangzhou, 18 and tianjin, 19 it remains legal and practiced elsewhere; but during covid-19, such practices markedly reduced. on may 15, 2020, the chinese government of shanxi province passed china's rst provincial law prohibiting spitting in public places, which aimed to change uncivilized behaviors and prevent the spread of infectious diseases. 20, 21 unlike physical distancing and handwashing that were widely recommended by public health authorities' sources, public spitting messages were mostly from non-o cial online sources. another explanation for a decrease in this behavior is that people remained inside more and such public spitting opportunities were less. these ndings do not appear to be driven by social desirability response since other hygienic measures that were not suggested in governmental and public sources, like showering, were not impacted. anxiety levels were high in this large sample. surveys from multiple countries, including china, 22 germany, 23 italy, 24 saudi arabia, 25 and turkey 26 have shown that the prevalence of anxiety increased signi cantly with the global escalation of the covid-19 pandemic. for example, prior to the covid-19 outbreak, the prevalence of anxiety among a national sample of 38,294 chinese urban dwellers was 5.3%, 27 and in a post-covid survey of 7,236 chinese citizens, 22 the prevalence rose to 35.1% using the same gad screening instrument. our study had a similar prevalence to the other, but we identi ed more factors that were correlated with gad. unlike the other survey that found younger age (<35 years) and time spent (>3 hours daily) focusing on covid-19, our assessment of urban dwellers found that gad was correlated with being a healthcare worker, living in region more profoundly impacted by covid-19, having poorer self-perceived health status, having a college education and having moderate to severe depression. findings from our urban study, combined with those from both urban and non-urban dwellers, underscores the importance of providing support to a large number of people impacted by a new and evolving epidemic. our ndings, however, provide important insights into how to focus such intervention efforts to provide trauma-informed care. for example, healthcare workers, which have been identi ed elsewhere to experience exceptional levels of stress, should be targeted for screening and intervention. additionally, those with lower self-perceived health should be targeted. many such individuals may potentially have co-morbid conditions that increase their likelihood of experiencing more severe covid-19 disease if they become infected. 28, 29 this is especially true since they may perceive they are unable to access needed healthcare services since during the pandemic, only essential medical visits were allowed, leaving them without support to self-manage their medical conditions. while patients with depression may also experience anxiety symptoms, in our survey, these variables were not collinear, but suggests that such patients have a lower psychological reserve to deal with stress and experienced heightened anxiety symptoms. this nding is born out in our additional analysis that shows depression is highly correlated with moderate to severe anxiety symptoms. in the initial stage of responding to covid-19, most healthcare facilities in the outbreak regions shuttered their doors to patients, except for those with urgent needs. consequently, care was transitioned to telehealth. one potential implication from this survey is that healthcare providers, when providing tele-health to patients with chronic diseases that may heighten risk for more severe consequences of covid-19, and even those with depression, should screen such patients for gad and provide supportive counseling, which can effectively be done using tele-health. 30 as pandemics evolve, unscienti c ideas may proliferate about how infections can be prevented, treated and cured. in the early stage of covid-19, rumors of several effective treatments were touted to suppress covid-19 from unsubstantiated online sources, which in turn generated the public anxiety because everyone wanted the treatments, yet they were unavailable for purchase. 31 providing accurate health information guided by science is therefore important to mitigate excess anxiety during the pandemic. unsubstantiated rumors have been found to provoke anxiety and exacerbate mental health before sars, avian u, and swine u epidemics. 32-34 in times of crisis, it is even more important to ensure information is accurate and scienti cally grounded to ensure that people feel safe. in the case of covid-19, considerable uncertainty existed and in an evolving crisis, conspiracy theories and hyperbole abound which, in turn, perpetuates anxiety. 35 health information, however, often comes from multiple sources, but should be derived from someone who is respected, has authority and trusted by society. during an infectious pandemic that requires physical distancing, mobile technology may be crucial as a conduit of accurate (and sometimes inaccurate) information. 36, 37 such information is more powerful, however, when collaborative learning is used and people can teach each other as long as an expert is there to guide discussion. 38 collaborative learning in communities, de ned as integrating meaningful community engagement with education, instruction, and re ection to promote the capacity of individuals to take collective actions to improve the quality of life, is a key method considered by many international and national bodies to prepare for, respond to, and recover from emergency situations. 39, 40 mobile technology-based interventions (e.g., telemedicine) could easily be repurposed to promote community learning not only as a dissemination method of accurate information, but also to address anxiety, maintain social connectivity while physically distancing, mobilize resources, and support communitybased networks of people in need. 41 for instance, a tele-health visit using video or telephone from local clinicians could screen, motivate and treat patients and families. even when stigma about mental illness is common, as it is in china, 27 brief motivational enhancement techniques can be deployed as part of trauma-informed care that can be done routinely without making a diagnosis. building such interventions and messages in public forums and giving people an opportunity to discuss how the pandemic is affecting them can provide an open opportunity for assistance. this would be especially crucial in some regions of mainland china where it might be considered "abnormal" or a shameful to seek treatment for anxiety. such individual or public messaging to provide trauma-informed care to individuals with anxiety would minimally include examples to support self-regulation of stressors, prioritize healthy relationships, explain why health restrictions are being made that otherwise limit routine daily activities, visualize what to expect within reason of what is known, and reframe behaviors to account for people not being at their best during times of crisis. 42 it is no surprise that urban dwellers living closest to the epicenter and with the high density of covid-19 cases (e.g., hubei) experienced the most anxiety, relative to those in less dense covid-19 cases. these individuals had the most uncertainty as they were impacted rst and had the least amount of accurate information. such individuals might have also perceived themselves at highest risk, which is similar to our nding that healthcare workers, also at substantial risk, experienced heightened anxiety symptoms. of note, healthcare workers had an increased association of experiencing mild anxiety symptoms, but not moderate or severe anxiety symptoms. one might expect that such individuals would have the most severe anxiety symptoms because they are at the highest risk for covid-19 combined with extreme workloads during a heightened crisis management scenario where personal protective equipment and testing were inadequate. 43 one potential explanation is that healthcare workers self-manage life and death situations on a daily basis and have established functional coping mechanisms. alternatively, data from wuhan suggested that over half of healthcare workers accessed support services, which may have helped them better deal with anxiety-provoking stressors. 44 last, the healthcare workers in this survey may not have been those providing the most direct patient care and therefore did not experience the highest levels of anxiety. though this large survey assessing responses and anxiety symptoms across a large number of regions of china had many important and new ndings, it is without limitations. first, convenience sampling using wechat does not make this a fully representative sample and restrict generalizability. second, though markedly higher levels of generalized anxiety disorders were reported relative to the general population before covid-19, we could not infer that covid-19 was causative due to the cross-sectional nature of the survey. last, some factors that may have contributed to anxiety symptoms may not have been measured, like time spent online seeking covid-related information or various types of coping mechanism. future research should more comprehensively study the possible negative psychological consequences of various countermeasures to nd out the best solution. finally, this study compared anxiety levels from before the outbreak to march 2020 but did not assess changes in anxiety levels over the entire period of the pandemic. more research should be conducted to examine changes in mental health outcomes over the entire pandemic period. covid-19 has had a profound impact on china initially and continues to do so globally. in china, urban residents markedly changed their health behaviors in response to the evolving epidemic. these urban dwellers also experienced profound levels of anxiety, especially in settings closest most profoundly impacted by the epidemic and in those most vulnerable like healthcare workers and those with poor perceived health, including those with depression. much has been learned from prior epidemics to guide a trauma-informed response, but when physical distancing practices are imposed, innovations in reaching screening, motivating and treating such individuals at increased risk for anxiety are urgently needed. technology-based interventions like online collaborative learning environments and tele-health can be used to solve such obstacles to service delivery. such lessons can be useful as new settings become susceptible to covid-19 and as secondary outbreaks emerge before an effective vaccine is made widely available. * in bivariate logistic regression models, those variables whose p-value is less than 0.1 was included in the multiple logistic regression. ** variables that have been significant at 0.05 level in multiple logistic regression model. ‡ participants who divorced or lost spouse were categorized into the categorize of married. a health-related behavior after the covid-19 outbreak. b health-related behavior before the covid-19 outbreak. compliance with ethical standards this work was supported by grants from the national institute on drug abuse for career development (k01da051346 to rs and k24 da017072 to fla). the authors have no con icts of interest to disclose. the study protocol was approved by the institutional review board of yale university and received ethical approval from wuhan university. 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. electronic informed consent was obtained from all individual participants included in the study. figure 1 in this study, we used a modi ed snowball recruitment strategy where 11 participants (seeds) were recruited one each from 11 representative provinces in china. eleven representative provinces were qinghai, ningxia, xinjiang);9 and 2) covid-19 severity as was categorized by china national health commission10 (diagnosed covid-19 cases≥10,000; 1,000-9,999; 100-999; ≤99) based on the percentage of provinces in each stratum in march 2020 note: the designations employed and the presentation of the material on this map do not imply the expression of any opinion whatsoever on the part of research square concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. this map has been provided by the authors. covid-19 dashboard by the center for systems science and engineering (csse) at johns hopkins university (jhu). available at covid-19: prevention and control measures in community changes in contact patterns shape the dynamics of the covid-19 outbreak in china fear and the front line mental health and psychosocial considerations during the covid-19 outbreak urban residents in states hit hard by covid-19 most likely to see it as a threat to daily life the mental health consequences of covid-19 and physical distancing: the need for prevention and early intervention centers for disease control and prevention. outbreaks can be stressful national health commission of the people's republic of china. 3 15 24 [the latest situation of covid-19 on chinese physicians' perspectives on the 2017 american college of cardiology/american heart association hypertension guideline: a mobile app-based survey application of "questionnaire star" in ideological and political theory courses of higher vocational colleges. the science education article collects back-translation for cross-cultural research a brief measure for assessing generalized anxiety disorder: the gad-7 the obsessive-compulsive inventory: development and validation of a short version the patient health questionnaire-2: validity of a two-item depression screener. med care xinhua news. available at hangzhou makes public spitting illegal the people's government of shanxi province generalized anxiety disorder, depressive symptoms and sleep quality during covid-19 outbreak in china: a web-based cross-sectional survey increased generalized anxiety, depression and distress during the covid-19 pandemic: a cross-sectional study in germany a nationwide survey of psychological distress among italian people during the covid-19 pandemic: immediate psychological responses and associated factors the psychological impact of covid-19 pandemic on the general population of saudi arabia levels and predictors of anxiety, depression and health anxiety during covid-19 pandemic in turkish society: the importance of gender generalized anxiety disorder in urban china: prevalence, awareness, and disease burden addressing the covid-19 pandemic in populations with serious mental illness a pilot randomized controlled trial of a depression and disease management program delivered by phone immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china this is a list of supplementary les associated with this preprint. click to download.supplementalappendix.docx key: cord-288568-fjdjuksm authors: huang, yuanyuan; wang, yanxia; zeng, lingyun; yang, jiezhi; song, xiuli; rao, wenwang; li, hehua; ning, yuping; he, hongbo; li, ting; wu, kai; chen, fengjuan; wu, fengchun; zhang, xiangyang title: prevalence and correlation of anxiety, insomnia and somatic symptoms in a chinese population during the covid-19 epidemic date: 2020-08-28 journal: front psychiatry doi: 10.3389/fpsyt.2020.568329 sha: doc_id: 288568 cord_uid: fjdjuksm background: anxiety has been a common mental state during the epidemic of coronavirus disease 2019 (covid-19) and is usually closely related to somatization. however, no study on somatization in anxiety and its relationship with insomnia has been conducted. therefore, this study aimed to identify the prevalence of anxiety, somatization and insomnia and explore the relationships between different psychological states in the general population during the covid-19 outbreak. methods: a total of 1,172 respondents were recruited from 125 cities in mainland china by an online questionnaire survey. all subjects were evaluated with the 7-item generalized anxiety disorder (gad-7) scale, the somatization subscale of the symptom checklist 90-revised (scl-90-r), and the 7-item insomnia severity index (isi). results: the percentages of anxiety, somatization, and insomnia were 33.02%, 7.59%, and 24.66%, respectively. the prevalence of somatization was 19.38% in participants with anxiety. compared to the anxiety without somatization group, the anxiety with somatization group had a significantly higher percentage of patients with a history of physical disease and insomnia, as well as higher gad-7 scores and scl-90 somatization subscores (all p < 0.001). the scl-90 somatization subscores were positively correlated with age, history of physical disease, gad-7 scores, and isi scores (all p < 0.001). furthermore, multivariate logistic regression showed that gad-7 score, isi score, and age were risk factors for somatization in the anxious population. conclusions: somatic and psychological symptoms were common in the general population during the covid-19 outbreak. somatic symptoms, anxiety, and insomnia are closely related, and improving anxiety and sleep quality may help relieve somatic symptoms. the covid-19 epidemic is a major public health emergency because of the disease's rapid spread, wide range of infections and difficulty to prevent and control (1) . according to the data released by the world health organization on april 5, the covid-19 epidemic has affected more than 200 countries and regions around the world, with more than 1.13 million confirmed cases. during the period of epidemic pressure, people's psychology, physiology and behavior change accordingly (2, 3) . if an individual's response is inappropriate or excessive, it can impact physical and mental health (4, 5) , causing anxiety, fear, insomnia, or somatic symptoms. a previous study revealed that psychological factors could play a crucial role in public health strategies to control epidemics and pandemics (6) . understanding and studying the psychological state of the public during the turbulent epidemic period is of practical significance for helping psychological professionals and the government to provide psychological support and behavioral guidance. anxiety is a common mental state that affects psychology and the body in the short and long term. a recent national survey in china showed that anxiety has the highest prevalence of all mental disorders at 4.98% (7) . approximately 10-30% of the public worried about the possibility becoming infected with virus during an influenza outbreak (8) (9) (10) . with the suspension of business and school and, in some cases, the closure of cities, personal anxiety becomes more complicated by the ongoing covid-19 epidemic (8) . wang c et al. (10) found that during the early stage of the epidemic, over 28% of chinese respondents suffered from moderate or severe anxiety symptoms. a crosssectional survey showed that approximately 25% of college students experienced anxiety during the outbreak (8) . to date, many studies have reported factors associated with anxiety during the outbreak. an increasing amount of evidence has revealed that being female, being a medical health worker, being acquainted with someone who has been infected and having organic disease elevate the risk of anxiety, while age greater than 40 years and family income stability decrease the risk (3, 8, 11, 12) . somatization and anxiety are usually closely related. in the general population, anxiety disorders often overlap with a variety of somatic symptoms (13) ; however, the correlation between physical symptoms and anxiety is inconsistent. some studies have identified that somatic symptoms are linked with psychological or physiological abnormalities, which could indicate a pathological condition (14) . meanwhile, raffagnato a et al. reported that patients expressed their mental state through somatization symptoms (15) . for example, approximately, 15%-45% of patients with persistent pain suffer from various degrees of anxiety (16, 17) . in contrast, previous studies showed that physical symptoms may occur independent of anxiety symptoms (18, 19) , but the mechanism underlying this finding is not yet clear. furthermore, several demographic and socioeconomic risk factors for somatic symptoms have been revealed, such as gender (female), age (older), marital status, chronic illnesses, and employment status (20) . insomnia and anxiety symptoms were also considered risk factors for somatic symptoms in a general population of hong kong (21) . few studies have examined somatic symptoms during the covid-19 epidemic. for instance, a survey of 1,255 nonmedical health workers found that the prevalence rate of somatization was 0.4% (12) . at present, several studies have reported the prevalence of anxiety, depression, insomnia, and other psychological states in the general population during the epidemic (1, 6-8, 10-12). however, there is a lack of research on the relationship between different mental states during this particular period, and no study on the prevalence of somatic symptoms in a population with anxiety and its relationship with insomnia or other mental states have not been reported. therefore, we investigated the public's mental health during the covid-19 epidemic and aimed to (1) explore the prevalence of anxiety, somatization, and insomnia in a chinese population; (2) examine the correlation between physical symptoms and psychological symptoms; and (3) provide a theoretical basis for intervention measures provided by psychologists and the government. using a cross-sectional design, an anonymous online questionnaire survey was used to assess the public's psychological status during the covid-19 epidemic. we adopted a snowball sampling strategy to focus on recruiting ordinary people who lived on the chinese mainland during the covid-19 epidemic. the online survey was initially distributed among college students, who were encouraged to pass it on to others. all respondents completed the survey in chinese by using ranxing technology "surveystar" to reduce faceto-face interaction. data collection was carried out during the covid-19 epidemic (from february 14 to march 29, 2020). inclusion criteria included (1) chinese individuals living on the mainland and (2) willingness to complete the survey. any subjects with psychotic disorders diagnosed in a medical institution were excluded. this study was approved by the ethics committee of the institute of psychology of the chinese academy of sciences. all participants provided informed consent before answering questions, and they could terminate the investigation at any time. in this study, the structured questionnaire included the following sections: (1) sociodemographic characteristics; (2) history of exposure to covid-19; (3) history of physical disease; and (4) psychological health status. sociodemographic data included sex, age, weight, height, marital status, education level, occupational status (student or not a student), economic loss, smoking status, and drinking status. furthermore, we asked an additional question: do you have relatives or friends who have been infected with covid-19? in addition, body mass index (bmi) was calculated based on height and weight. age was divided into four groups: 20 years old or below, 21-30 years old, 31-40 years old, and older than 40 years old. anxiety, physical symptoms, and insomnia in the general population were assessed by the chinese version of the 7-item generalized anxiety disorder (gad-7) scale, the chinese version of the somatization subscale of the symptom checklist 90-revised (scl-90-r), and the 7-item insomnia severity index (isi). these self-reported scales have good reliability and validity for measuring psychological status (11, 22, 23) . the gad-7 was used to screen for generalized anxiety and assess the severity of symptoms. scores range from 0 (not present) to 21 points (extremely severe), and a score of ≥ 5 indicates the presence of anxiety symptoms (24, 25) . the isi scale was used to evaluate the presence and severity of insomnia. the total score of the isi scale varies from 0 (not present) to 28 points (severe), and a cut-off value of 8 indicates the presence of insomnia (26) . somatic symptoms were identified by the somatization subscale of the scl-90-r, which consists of 12 items (cronbach's a = 0.83) scored on a five-point likert scale: none (1), mild (2), moderate (3), fairly severe (4), and severe (5) . the total score of the subscale ranges from 12 (not present) to 60 points (extreme); the higher the score, the stronger the participant's physical discomfort is. according to results normed on a chinese population, a total score higher than 24 points (single factor score ≥ 2) indicates the presence of somatic symptoms (12, 27) . data analysis was conducted using spss (version 18.0) software. normally, distributed data are presented as the mean ± standard deviation (sd), and count data are presented as the number of people (%). demographic and clinical variables were compared between groups by analysis of variance (anova) for continuous variables and chi-squared tests for categorical variables. since the original scores of all scales are not normally distributed (kolmogorov-smirnov test, p < 0.05), the data are expressed as medians with interquartile ranges. the nonparametric mann-whitney u test was used to compare each symptom between groups. relationships between scl-90 somatization subscores and demographic and clinical variables were examined using spearman correlation analysis. multivariate logistic regression analysis ("enter" model) was then used to assess the relevant factors associated with somatization symptoms. somatic symptoms (yes or no) in anxious participants were regarded as the dependent variable, while factors that showed statistical significance in chi-squared tests and u tests were regarded as the independent variables. a p value <0.05 (twotailed) was considered statistically significant. altogether, 1,172 respondents (812 females and 360 males) were recruited from 125 cities in china. their average age was 28.39 ± 10.49 years. among them, 287 people (24.49%) were aged ≤ 20 years, 443 people (37.80%) were aged 21-30 years, 285 people (24.32%) were aged 31-40 years, and 157 people (13.39%) were above 40 years old. education levels were as follows: high school degree or below (167, 14.25%), technical or mechanical degree (223, 19.03%), bachelor's degree (675, 57.59%), and master's degree or above (107, 9.13%). more than half of the participants (587, 50.09%) were students. approximately half of the participants (585, 49.91%) experienced economic loss during the epidemic period. a total of 153 participants (13.05%) had a history of physical diseases. only 8 (0.68%) participants had relatives and friends who suffered from covid-19. the detailed sociodemographic information is presented in table 1 . the prevalence of anxiety, somatization, and insomnia in a chinese population during the covid-19 epidemic was 33.02% (387/1172), 7.59% (89/1172), and 24.66% (289/1172), respectively. the proportion of somatization among participants with anxiety was 19.38% (75/387). as shown in table 1 , there was no significant difference in demographic characteristics between the subjects with anxiety (n = 387) and subjects without anxiety (n = 785; all p > 0.05), except for economic loss (p = 0.001), history of physical disease (p < 0.001), and drinking (p = 0.044). furthermore, the anxiety group had higher gad-7 scores, scl-90 somatization subscores, and isi scores than the non-anxiety group (all p < 0.05). multivariate logistic regression analyses found that participants who experienced economic loss had a 1.3 times higher probability of anxiety symptoms than participants without economic loss (or = 1.30, 95% ci: 1.05-1.57, wald x 2 = 5.74, p = 0.017), while no significant difference in history of physical disease and drinking was found (p >0.05). higher scl-90 somatization subscores (or = 1.10, 95% ci: 1.07-1.14, wald x 2 = 37.15, p < 0.001) and isi scores (or = 1.17, 95% ci: 1.13-1. 19 , wald x 2 = 104.25, p < 0.001) were associated with a greater risk of anxiety. the demographic data of participants with anxiety in the nonsomatization group (n = 312) and the somatization (n = 75) group are presented in table 2 . there was a significant difference in age between the two groups (c2 = 8.608, p = 0.035). among those with anxiety, a higher proportion of subjects over 40 years old showed somatization, and a lower proportion of those aged 20 years or younger showed somatization. compared to the non-somatization subgroup of anxious participants, a significantly higher percentage of anxious participants with somatization group had a history of physical disease (c2 = 10.490, p = 0.030) and insomnia (c2 = 39.316, p < 0.001). mann-whitney u test analysis showed that in the anxiety group, participants with somatization had higher gad-7 scores, scl-90 somatization subscores and isi scores than nonsomatization participants (all p < 0.001). however, there was no significant difference in sex, bmi, marital status, education level, occupation, economic loss, smoking, and drinking between the participants in the somatization and non-somatization subgroups (all p > 0.05). as shown in table 3 , multivariable logistic regression analysis was used to explore the risk factors for anxiety with somatization symptoms. the findings showed that gad-7 scores (or = 1.158, 95% ci: 1.085-1.236, wald x 2 = 19.446, p < 0.001), isi scores (or = 1.087, 95% ci: 1.036-1.140, wald x 2 = 11.697, p = 0.001), and age (or = 1.743, 95% ci: 1.049-2.894, wald x 2 = 4.606, p = 0.032) were associated with somatization symptoms in anxiety participants, while no difference in history of physical disease was found (p > 0.05). in the participants in the anxiety with somatization group, spearman correlation analysis showed that scl-90 somatization subscores were positively correlated with age (r = 0.192, p < 0.001), bmi (r =0.100, p = 0.049), history of physical disease (r = 0.236, p < 0.001), gad-7 scores (r = 0.378, p < 0.001), and isi scores (r = 0.434, p < 0.001) (figure 1) . however, in the anxiety without somatization group, scl-90 somatization subscores were only positively correlated with gad-7 scores (r = 0.197, p < 0.001) and isi scores (r = 0.316, p < 0.001), and no significant correlation was found between scl-90 somatization subscores and age, history of physical diseases, and bmi (all p > 0.05). to the best of our knowledge, this is the first study to explore the prevalence of somatic symptoms and their related factors in a population with anxiety during the covid-19 epidemic in mainland china. the main findings of this study are as follows: (1) the prevalences of anxiety, somatization, and insomnia were 33.02%, 7.59%, and 24.66%, respectively; (2) the prevalence of somatization in the population with anxiety was 19.38%; (3) patients in the anxiety with somatization group were more likely to have a history of physical disease and insomnia, older age, and higher gad-7 scores; and (4) somatic symptoms were closely associated with anxiety and insomnia. in our study, approximately one-third of the mainland chinese respondents reported anxiety symptoms using the gad-7 scale, which was consistent with most previous studies conducted during the covid-19 outbreak. for example, a number of studies revealed that a relatively high proportion of the public (20-30%) experienced anxiety symptoms (8, 10) . due to the adverse effects of epidemics, such as fears of infection, limitations of social activities and daily life, and inevitable stress, mental health problems might arise (28) . a survey including 600 subjects from china showed that only 6.33% of participants felt anxious (3). the differences in these studies might be partly attributed to differences in survey areas, interviewees, periods of the epidemic (initial, outbreak, and remission), measurements, etc. in addition, a consistent conclusion is that compared with the percentage (less than 5%) of the public with anxiety symptoms during the non-epidemic period (7, 13), a larger proportion of people present anxiety symptoms during the outbreak. the government and psychologists should constantly focus on the mental health of the public during this unique period. furthermore, our study found that anxiety was associated with economic loss, a history of physical disease, and increased isi scores, which is in line with previous studies (8, 29, 30) . interestingly, our study also demonstrated that anxious people were likely to have more somatic symptoms than people without anxiety symptoms. our survey further revealed a high proportion (19.38%) of somatic symptoms among the population with anxiety; this proportion was over 2 times more than the proportion of somatization for the whole sample (7.59%). in previous studies, the probability of somatization among people with anxiety fluctuated widely (ranging from 1.5% to 25%), depending on the different definitions of somatization used (31) (32) (33) (34) . most studies defined physical symptoms in terms of both physical and psychological aspects (35) . however, our study defined somatization as any discomfort, including unexplained and explained physical symptoms, that was equally strongly associated with anxiety (20) . using different self-rating scales instead of a standardized diagnosis to assess physical symptoms may be another reason for the inconsistent results (36, 37) . moreover, when people with physical diseases experience various physical discomforts, some of these symptoms can presented as psychological symptoms (38) . rosmalen and his panel reported that 11.8% of subjects in the general population with somatic symptoms suffered from depression or anxiety disorders (39) . a 3-year follow-up study showed that the proportion of physical symptoms (both unexplained and explained symptoms) comorbid with any anxiety disorder was 17.4% (40) . in addition, because findings regarding somatization show significant discrepancies and few studies have reported on somatization in anxiety, it is of great significance to investigate the factors related to the presence of somatic symptoms in people with anxiety. our study also found a significant difference in the history of physical diseases between the somatization and non-somatization subgroups of respondents with anxiety, which was similar to the findings of previous studies showing that chronic illness was highly correlated with somatic symptoms (12, (41) (42) (43) . unlike the findings from a population-based survey conducted in a chinese general population, chronic illness was not related to somatic symptoms (21) . the presence of different types of physical diseases may partly explain the differences between the two studies (21) . specifically, some diseases (osteoporosis, gout, arthritis, and low back pain) cause pain, while others (psychiatric illness, hypertension, diabetes, etc.) rarely cause pain. similar to an early study in hong kong (20) , age was identified as a risk factor for somatization in individuals with anxiety. nevertheless, other studies did not observe significant differences between different ages (21) . moreover, in contrast to previous studies (10, 44) , no significant differences were observed in occupation status (students or others) and sex (male or female) between the two different anxiety subgroups, indicating that people with different occupations and genders suffered from similar physical and psychological states during this epidemic. compared with respondents without somatic symptoms, a greater proportion of respondents with anxiety and somatization suffered from insomnia and had higher isi scores. additionally, the correlation analysis further explained the positive correlation between insomnia scores and scl-90 somatization subscores. a cross-sectional study involving 47,000 participants indicated that insomnia was closely related to somatic symptoms, similar to our results (45) . we also demonstrated that the gad-7 score was positively correlated with anxiety with comorbid somatization. the findings were consistent with those of several previous studies suggesting a close association between anxiety and somatization (12, 21, 44) . a similar study (46) reported that compared with nonanxious people, anxiety patients were more sensitive to physical changes and had higher scores for psychological and physical symptoms, which could be explained by certain biological mechanisms (21) . for example, an increasing level of anxiety can cause an increase in heart rate and blood pressure (47) , which may also play a role in physical discomfort, such as the feeling of heart pressure. in addition, anxiety may trigger pain, which is related to increased muscle tension (48) . wilson and his colleagues also reported that anxiety may cause visceral allergies, resulting in exacerbated gastrointestinal discomfort (49) . gad-7 and isi scores were regarded as predictive indicators of somatization in people with anxiety in the multivariate logistic regression analysis. moreover, our research also demonstrated that somatization, anxiety, and insomnia coexist in the general population (13, 21) . anxiety may affect sleep quality by causing changes in hormone levels (such as increasing cortisol levels and decreasing melatonin synthesis) (50) . improving anxiety and sleep quality may help alleviate physical symptoms (21) . however, due to the defects of cross-sectional studies, our study only reflected certain associations, and longitudinal studies are required to demonstrate causal relationships in the future. several limitations should be considered. first, due to the covid-19 outbreak, a survey conducted by online questionnaires may have selection bias. these voluntary online surveys cannot artificially set the male-to-female ratio, and the imbalance between males and females may impact the results; thus, gender differences must be analyzed in the future. moreover, the system cannot count the number of people who opened the connection but did not complete the questionnaire, so it is impossible to report the response rate. second, clinical symptoms were assessed by a self-assessment scale instead of a standardized psychiatric diagnosis; however, the self-assessment scale has good reliability and validity. third, this is a cross-sectional study, and it cannot explain internal causal relationships. fourth, due to the requirements of epidemic prevention and control, covid-19 patients (including asymptomatic infections) are admitted to hospital for isolation treatment, so we do not include diagnosed patients in this study, which may affect causal analyses. fifth, in this study, we excluded any subjects who had been clearly diagnosed with psychotic disorders in a medical institution, which may have a certain impact on the incidence of anxiety, insomnia, and somatization. in conclusion, our study demonstrated that anxiety, insomnia, and somatic symptoms were common in the general population during the covid-19 epidemic. moreover, somatic symptoms, anxiety, and insomnia are closely related, and improving anxiety and sleep quality may help relieve somatic symptoms. therefore, we should pay attention to the mental state of the public during the covid-19 epidemic and formulate relevant measures to intervene in cases of psychological problems. all datasets presented in this study are included in the article/ supplementary material. the studies involving human participants were reviewed and approved by the ethics committee of the institute of psychology of the chinese academy of sciences. the patients/participants provided their written informed consent to participate in this study. a novel coronavirus outbreak of global health concern study on the public psychological states and its related factors during the outbreak of coronavirus disease 2019 (covid-19) in some regions of china facilitating collective psychosocial resilience in the public in emergencies: twelve recommendations based on the social identity approach psychological impact of the 2015 mers outbreak on hospital workers and quarantined hemodialysis patients how health anxiety influences responses to viral outbreaks like covid-19: what all decision-makers, health authorities, and health care professionals need to know prevalence of mental disorders in china: a cross-sectional epidemiological study the psychological impact of the covid-19 epidemic on college students in china the impact of communications about swine flu (influenza a h1n1v) on public responses to the outbreak: results from 36 national telephone surveys in the uk immediate psychological responses and associated factors during the initial stage of the covid-19) epidemic among the general population in china factors associated with mental health outcomes among health care workers exposed to coronavirus disease mental health and psychosocial problems of medical health workers during the covid-19 epidemic in china the overlap of somatic, anxious and depressive syndromes: a population-based analysis depression and pain: an overview using the body when there are no words for feelings: alexithymia and somatization in self-harming adolescents depression and pain comorbidity: a literature review relationships among pain, anxiety, and depression in primary care genetic and environmental contributions to the overlap between psychological, fatigue and somatic symptoms: a twin study in sri lanka the structure of genetic and environmental risk factors for syndromal and subsyndromal common dsm-iv axis i and all axis ii disorders psychometric properties of the chinese 15-item patient health questionnaire in the general population of hong kong anxiety and insomnia as modifiable risk factors for somatic symptoms in chinese: a general population-based study sensitivity to change and minimal clinically important difference of the 7-item generalized anxiety disorder questionnaire (gad-7) insomnia severity index: psychometric properties with chinese community-dwelling older people a brief measure for assessing generalized anxiety disorder: the gad-7 clinical characteristics and related factors of somatization symptoms in outpatients with psychiatric disorders of the department of cardiology in general hospitals individually tailored internet treatment in routine care: a feasibility study psychological results of 438 patients with persisting gastroesophageal reflux disease symptoms by symptom checklist 90-revised questionnaire a cross-sectional survey of disability attributed to mental disorders and service use in china effect of transcranial alternating current stimulation for the treatment of chronic insomnia: a randomized, double-blind, parallel-group, placebo-controlled clinical trial negative life events and mental health of chinese medical students: the effect of resilience, personality and social support somatoform disorders in general practice: prevalence, functional impairment and comorbidity with anxiety and depressive disorders physician-based estimates of medically unexplained symptoms: a comparison of four case definitions classification characteristics of the patient health questionnaire-15 for screening somatoform disorders in a primary care setting whether medically unexplained or not, three or more concurrent somatic symptoms predict psychopathology and service use in community populations systematic review of measurement properties of questionnaires measuring somatization in primary care patients distinct associations of dsm-5 somatic symptom disorder, the diagnostic criteria for psychosomatic research-revised (dcpr-r) and symptom severity in patients with irritable bowel syndrome the epidemiology of multiple somatic symptoms beyond "somatization" and "psychologization": symptom-level variation in depressed han chinese and euro-canadian outpatients empirical foundations for the diagnosis of somatization: implications for dsm-5 medically unexplained and explained physical symptoms in the general population: association with prevalent and incident mental disorders depressive symptoms in people with chronic physical conditions: prevalence and risk factors in a hong kong community sample adèr hj, van der feltz-cornelis cm. a high physical symptom count reduces the effectiveness of treatment for depression, independently of chronic medical conditions adverse effects of multiple physical symptoms on the course of depressive and anxiety symptoms in primary care alexithymia and somatization in depressed patients: the role of the type of somatic symptom attribution the epidemiology of insomnia: associations with physical and mental health. hunt-2 study somatic symptoms and physiologic responses in generalized anxiety disorder and panic disorder: an ambulatory monitor study autonomic nervous system activity in emotion: a review muscle tension in generalized anxiety disorder: a critical review of the literature the psychobiological etiology of gastrointestinal distress in sport: a review melatonin and its analogs in insomnia and depression conflict of interest: the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited all authors contributed to the study design and data interpretation. fw and xz were responsible for the management and oversight of the study. yh and yw were responsible for general omnibus data analyses and were the key contributing authors of the manuscript. lz, jy, xs, hl, fc, and tl were responsible for all research interviews and clinical chart reviews associated with this study. yn and bh provided guidance on the design of the primary analyses. wr and kw assisted with all data collection, analysis, and writing of the manuscript. all authors contributed to the article and approved the submitted version. the authors thank all the participants who shared their experiences for this survey. key: cord-027578-yapmcvps authors: menzies, rachel e.; menzies, ross g. title: death anxiety in the time of covid-19: theoretical explanations and clinical implications date: 2020-06-11 journal: cogn behav therap doi: 10.1017/s1754470x20000215 sha: doc_id: 27578 cord_uid: yapmcvps the recent covid-19 pandemic has triggered a surge in anxiety across the globe. much of the public’s behavioural and emotional response to the virus can be understood through the framework of terror management theory, which proposes that fear of death drives much of human behaviour. in the context of the current pandemic, death anxiety, a recently proposed transdiagnostic construct, appears especially relevant. fear of death has recently been shown to predict not only anxiety related to covid-19, but also to play a causal role in various mental health conditions. given this, it is argued that treatment programmes in mental health may need to broaden their focus to directly target the dread of death. notably, cognitive behavioural therapy (cbt) has been shown to produce significant reductions in death anxiety. as such, it is possible that complementing current treatments with specific cbt techniques addressing fears of death may ensure enhanced long-term symptom reduction. further research is essential in order to examine whether treating death anxiety will indeed improve long-term outcomes, and prevent the emergence of future disorders in vulnerable populations. key learning aims: (1).. to understand terror management theory and its theoretical explanation of death anxiety in the context of covid-19. (2).. to understand the transdiagnostic role of death anxiety in mental health disorders. (3).. to understand current treatment approaches for directly targeting death anxiety, and the importance of doing so to improve long-term treatment outcomes. in december 2019, a novel coronavirus was first detected in the city of wuhan, china. within five weeks, the virus, now named covid-19, began to dominate global headlines. by mid-may 2020, covid-19 had resulted in the deaths of more than 300,000 people worldwide, with nearly 4.5 million cases confirmed (world health organization, 2020). as cases increased, governments around the world began closing borders, and introducing social distancing restrictions and lockdown orders, in an effort to slow the rapid acceleration of the virus. prior to many of these government responses, reports emerged of individuals choosing to self-isolate, as mass panic swept through communities in waves. anecdotal reports of verbal and physical aggression in grocery stores, hoarding of antibacterial products and other supplies, and racist abuse of individuals with asian appearance increased as fear took over across the world (devakumar et al., 2020; garfin et al., 2020) . as individuals scrambled to prevent the threat of covid-19 in any way they could, online sales of 'immune boosters' and untrialled medicines increased. analyses of google data across just 14 days in march 2020 revealed a total of 216,000 searches for where to purchase chloroquine and hydroxychloroquine, two drugs which were touted by the media as potentially effective, despite the existing clinical evidence for the efficacy of these drugs being inconclusive (liu et al., 2020) . emerging research data are already revealing high levels of anxiety concerning the virus, with findings from nearly 5000 participants suggesting that greater perceived severity of the virus is associated with poorer mental health outcomes (li et al., 2020) . arguably, this response from the public should not come as a surprise. fears of death have been proposed to be a central and universal part of the experience of being human (becker, 1973) . in fact, there is evidence of humans grappling with death anxiety for as long as our species has been recording its history (menzies, 2018b) . we are the only species that we know of that has the cognitive capacity to contemplate and anticipate our own death, yet this impressive ability comes with a downside; we are destined to live our lives 'forever shadowed by the knowledge that we will grow, blossom, and inevitably, diminish and die' (yalom, 2008, p. 1 ). on the one hand, people may develop adaptive ways of coping with their fear of death, such as building meaningful relationships and leaving a positive legacy (yalom, 2008) . on the other hand, awareness of death may also produce a powerful sense of fear or meaninglessness, and may drive a number of maladaptive coping behaviours (menzies, 2012) . some of these behaviours (e.g. avoidance) may underlie numerous mental health conditions, while other behaviours may appear, on the surface, not directly linked to death at all. how might our fears of death be shaping our everyday behaviour in ways that we are not even aware of? terror management theory terror management theory (tmt), a social psychological theory based on the work of cultural anthropologist ernest becker, is the leading psychological framework for explaining this effect of death fears on human behaviour (greenberg et al., 1992) . tmt posits that our awareness of our own death produces a crippling terror, and that humans have developed two distinct buffers in order to allay this fear: cultural worldviews, and self-esteem. cultural worldviews involve shared symbolic concepts of the world, including identifying with cultural values or endorsing belief systems, such as the belief in an afterlife. sharing these cultural worldviews is thought to offer a sense of 'symbolic immortality', by giving an individual a sense of permanence and meaning in the face of death. secondly, self-esteem, gained through fulfilling the expectations of our cultural worldview, is also said to buffer death anxiety, by making one feel like a valuable member of their culture, who will be remembered after death (greenberg, 2012) . tmt also proposes that humans use different defence mechanisms depending on whether thoughts of death are within or outside of conscious awareness. according to this 'dual process model', when thoughts of death are conscious, we engage in 'proximal defences', which include suppressing these thoughts (e.g. turning off a news report about covid-19 death tolls), denying one's vulnerability (e.g. 'i'm not in a high risk group, so i'll probably be fine'), or trying to prevent death (e.g. cleaning down all home surfaces with antibacterial wipes) . on the other hand, when thoughts of death leave conscious awareness, we instead engage in 'distal defences', which involve bolstering our two buffers (e.g. by endorsing our cultural worldviews, or enhancing our self-esteem). findings from hundreds of studies have demonstrated support for tmt (burke et al., 2010) . primarily, these studies have involved a 'mortality salience' design, in which participants in one condition are reminded of their mortality, while participants in the control condition are reminded of an aversive topic that is unrelated to death. these studies have shown that reminders of death drive a vast array of human behaviours, including intention to purchase products (dar-nimrod, 2012) , driving behaviour (taubman-ben-ari et al., 1999) , and even suntanning (routledge et al., 2004) . despite some recent studies questioning the replicability of tmt results (e.g. klein et al., 2019) , follow-up studies have demonstrated that classic tmt findings do replicate when sufficiently powered (chatard et al., 2020) . in addition, burke et al.'s (2010) review of 277 tmt experiments found that death reminders yielded moderate effects on a range of behavioural variables, with little evidence of publication bias, further highlighting the strength of mortality salience effects. given this, what role might death anxiety be playing in the current pandemic? death anxiety and the covid-19 pandemic with the exception of a handful of studies, the majority of tmt research has been conducted under laboratory conditions; i.e. for those in the mortality salience condition, death is usually primed in the form of two short questions about one's death, which participants are asked to respond to. covid-19 offers an unusual scenario, in which mortality is made salient nearly constantly, given the daily updates on death tolls from the news and social media, and ubiquitous visible death cues in the form of face masks, anti-bacterial sprays and wipes, social distancing and public health campaigns. supporting this idea, laboratory findings have demonstrated that reflecting on current epidemics or virus outbreaks (e.g. ebola, swine flu) produces comparable findings to standard mortality salience primes, increasing the accessibility of death-related thoughts, and increasing defensive behaviour (e.g. arrowood et al., 2017; bélanger et al., 2013; van tongeren et al., 2016) . although it is currently unknown what the long-term effects of mortality salience primes are, the consequence on human behaviour of even minor, subtle reminders of death under laboratory conditions have much to tell us about the behaviours observed during the current pandemic. first, from this perspective, the observed reports of both covert and overt racism towards asian individuals are unsurprising. these observations are supported by a recent study that found a positive relationship between coronavirus-related anxiety and avoidance of chinese food and products (lee, 2020) , echoing similar observations of avoidance of chinese people following the 2003 sars outbreak (keil and ali, 2006) . these experiences offer a real-world confirmation of the tmt laboratory findings that reminders of death lead people to feel more hostile towards those of different cultural backgrounds to their own, as they are seen as a threat to one's own worldviews. findings across a number of studies reveal that reminders of death increase stereotypical thinking about people of other races (schimel et al., 1999) , increase aggression against those who criticise one's nation (mcgregor et al., 1998) , and lead white participants to hold more favourable reactions to white pride advocates (greenberg et al., 2001) . one study even found that germans interviewed in front of a cemetery reported strongly preferring german products over foreign products, whereas germans interviewed in front of a shop did not show this preference (jonas et al., 2005) . similar effects have been observed in more than 12 countries worldwide (greenberg and kosloff, 2008) . so, much of the recent upsurge in xenophobia, or even hostility towards those with different political views, can be explained by the tmt notion that bolstering our cultural worldviews, and aggressing against those that threaten them, are one means of gaining a sense of symbolic immortality. this idea is further supported by the recent observation of mutual discrimination between east asian societies in the midst of the pandemic (e.g. individuals in taiwan avoiding contact with koreans and japanese individuals; lin, 2020) . whilst the bolstering of one's cultural worldviews is an example of distal defences being engaged during the pandemic, proximal defences, in the form of attempts to ward off death (e.g. spikes in purchases of hydroxychloroquine, a drug falsely touted as a cure to the virus) or denial have also been observed (jong-fast, 2020). furthermore, despite the unsurprising recency of much of the research, some preliminary data support the idea that death anxiety may be driving a significant amount of psychological distress during this pandemic. evaluation of the psychometric properties of the fear of covid-19 scale revealed that the item 'i am afraid of losing my life because of coronavirus-19' had the highest factor loading, suggesting that one's worry about one's own fatality risk is highly predictive of broad fears of the virus (ahorsu et al., 2020) . data from 1210 residents of china revealed that estimates of fatality also appear to specifically predict their psychological distress, with low estimates of one's own survival from covid-19 predicting greater levels of stress and depression on the depression, anxiety and stress scale dass-21 (wang et al., 2020) . one large study of 810 australians specifically explored fears of death in the context of the pandemic (newton-john et al., 2020). the findings revealed a significant positive correlation between death anxiety and anxious beliefs and behaviours related to covid-19 (e.g. estimated likelihood of contracting the virus, estimated likelihood of wearing a mask in public, etc.), in addition to self-reported health anxiety, and overall psychological distress. furthermore, participant responses to items assessing beliefs surrounding the virus indicated a heightened perception of threat. for example, when participants were asked how likely they would be to die if they contracted covid-19 in the next 18 months, the mean likelihood estimate was 22%, a figure more than 11 times the actual australian case fatality rate of <2%. so, while death anxiety may indeed be a driving factor in everyday human behaviour, it appears more relevant than ever in the context of the current pandemic. covid-19 may be understood as a real-life and ever-present mortality salience prime, influencing people's behaviour in ways they may not even be consciously aware of. early findings suggest that fears of death predict anxiety about the virus, which in turn is shown to predict broader psychological distress. these findings may suggest a causal relationship between death anxiety and psychological distress, and this relationship may be exacerbated in the current pandemic. death anxiety has been proposed to be a transdiagnostic construct, underpinning a range of different mental health conditions (iverach et al., 2014) . for instance, fears of death may manifest in the frequent reassurance seeking from doctors, checking of one's body, and requests for medical testing seen in the somatic symptom-related disorders (furer et al., 2007) . in a similar vein, panic disorder often features worries about heart attacks during panic attacks, in addition to repeated appointments with cardiac specialists to allay these concerns (starcevic, 2007) . specific phobias have been argued to have death anxiety at their core for over a century (kingman, 1928) , with all of the common phobic objects having the potential to directly result in death (e.g. fears of spiders, snakes, flying and heights). fears of death have also been argued to play a central role in various presentations of obsessive compulsive disorder, as clients attempt to prevent death by illness (in the contamination subtype), household fire or electrocution (in compulsive checking), and death to oneself or another due to acting on intrusive thoughts (as seen in aggressive obsessions) (menzies and dar-nimrod, 2017; menzies et al., 2015) . existential concerns have also been argued to play a role in the depressive disorders, with concerns surrounding death and meaninglessness being a common theme (ghaemi, 2007; simon et al., 1998) . a number of studies have demonstrated significant relationships between self-reported death anxiety and symptomology of various disorders, including separation anxiety (caras, 1995) , hypochondriasis (noyes et al., 2002) , post-traumatic stress disorder (martz, 2004) , depression (ongider and eyuboglu, 2013) and eating disorders (le marne and harris, 2016). results from one large clinical sample found significant and positive correlations between death anxiety and number of lifetime mental health diagnoses, number of medications for mental health, dass-21 depression, anxiety and stress scores, as well as the symptom severity of 12 different disorders . notably, these relationships remained significant after controlling for neuroticism, suggesting the unique role of death anxiety in psychopathology. while limited conclusions regarding causality can be drawn from such correlational designs, a handful of studies have explored the causal role of death anxiety in mental illnesses using a mortality salience design. these have revealed that reminders of death increase avoidance of spider-related stimuli among spider phobics (strachan et al., 2007) , social avoidance (strachan et al., 2007) and attentional biases towards threat among the socially anxious (finch et al., 2016) , and even restricted consumption of high caloric foods amongst women, suggesting the relevance of death anxiety in eating disorders (goldenberg et al., 2005) . while few studies have used clinical samples, one study investigated the effect of mortality salience on compulsive handwashing, utilising a large sample of treatment-seeking individuals diagnosed with ocd (menzies and dar-nimrod, 2017) . participants were first primed with either death or a control topic. following a short delay to allow the effects of the prime to become unconscious, they were asked to wash their hands. the findings revealed that reminders of death doubled the time spent handwashing. notably, this increase in handwashing occurred despite no difference in reported anxiety or perceptions of cleanliness. results from another recent mortality salience design appear particularly relevant to the current pandemic. across a sample of participants with panic disorder or a somatic symptom-related disorder, reminders of death were shown to increase time spent checking one's body for physical symptoms, increase perceived threat of one's symptoms, and also increase intention to visit a medical specialist in the near future . these findings suggest that death anxiety drives relevant anxious behaviour for those vulnerable to health-related worries. results from numerous studies appear to suggest that fear of death is indeed a transdiagnostic construct driving a number of mental health conditions, although further research using treatment-seeking and clinical samples is clearly warranted. if death anxiety does underlie numerous disorders, this may explain the 'revolving door' phenomenon often observed in clinical practice, in which an individual receives apparently successful treatment for one disorder, only to present with a distinctly different disorder at a later time point (iverach et al., 2014, p. 590) . if death anxiety is indeed 'the worm at the core' (james, 1985, p. 119) of the human psyche, then failing to treat it may result in individuals continuing to present with different mental health conditions at various points across their lifespan. fear of death may need to be assessed and explicitly targeted in treatment in order to achieve long-term amelioration in symptoms and foster ongoing client wellbeing. as with any target of clinical treatments, a thorough assessment paves the way to the most effective treatments of death anxiety, tailored to the individual's unique needs. the clinical interview in early sessions should focus on exploring the topic of death, including assessing for any early losses, memories, or experiences associated with death (menzies and veale, 2020) . it is also essential to assess the individual's specific worries or thoughts about death, as these can vary largely between individuals. for example, worries may revolve around the dying process itself (e.g. pain or loss of cognitive capacities), the feared death of a loved one, fears concerning eternal punishment in the afterlife, uncertainty surrounding life after death, or non-existence itself, and each theme may need to be addressed using distinctly different lines of cognitive challenging. maladaptive behaviours the individual engages in should also be identified during the assessment stage, including any avoidance behaviours (e.g. avoiding the news, hospitals, flying or driving, or suppressing thoughts around death), reassurance seeking (e.g. from family or one's doctor), self-medicating, or compensatory behaviours (e.g. excessive exercise) (menzies and veale, 2020) . in the context of the current pandemic, it would be important to distinguish behaviours which are adaptive (i.e. behaviours generally recommended by health professionals and public officials, such as wearing a face mask when leaving the house, self-isolating when symptomatic, and regularly washing one's hands for recommended durations) compared with those that are maladaptive (i.e. behaviours that are not in line with standard recommendations and disrupt the individual's life, such as washing one's hands for hours each day, or requesting repeated medical tests for the virus despite lack of symptoms). alongside a standard clinical interview, questionnaires can prove useful in measuring severity of death fears, as well as tracking change following treatment. one recent systematic review of death anxiety measures revealed that there is a strong need for rigorous measures which have been validated in clinical samples, and that many measures in this field lack adequate psychometric properties (zuccala et al., 2019) . despite this, a number of measures may prove particularly useful in assessing death anxiety. these include the collett-lester fear of death scale-revised (lester, 1990) , which has been demonstrated to be responsive to treatment effects, and thus appears to be the best choice for exploring clinical change, and the multidimensional fear of death scale (hoelter, 1979) , for which means for various clinical groups have been reported . the death attitude profile-revised (wong et al., 1994) may also offer clinical utility, due to its unique assessment of adaptive attitudes, such as three distinct types of death acceptance, which have been shown to predict more positive outcomes (tomer and eliason, 2000) . despite being understood to be an 'existential given' (yalom, 1980) , empirical findings fortunately indicate that death anxiety can indeed be ameliorated. one recent meta-analysis examined the effects of randomised controlled trials on death anxiety (menzies et al., 2018) . this revealed that psychosocial interventions produced significant reductions in death anxiety relative to control conditions. notably, this effect was found to be driven by cognitive behaviour therapy (cbt) interventions, which produced significantly greater improvements in death fears compared with other treatment modalities. in particular, cbt treatments centring on graded exposure therapy were found to be most effective. in fact, alternative treatment options examined by the meta-analysis failed to produce any significant change in death anxiety scores (menzies et al., 2018) . given these meta-analytic findings, cbt appears to be the most appropriate treatment for addressing death anxiety, and various techniques for doing so have been proposed (see further, menzies, 2018a; menzies and veale, 2020) . a number of exposure therapy tasks have been recommended in order to ameliorate death anxiety. of course, as with any exposure tasks, these should be specifically tailored to the individual's own unique pattern of avoidance, and situations or themes that the individual has systematically avoided should be prioritised. one exposure task that can be tailored to the individual's specific concerns is that of an 'illness story', recommended by furer et al. (2007) . this involves writing a vivid description of the death of oneself or a loved one, starting with the events leading up to the death (e.g. the initial diagnosis of a terminal illness), progressing to the death itself, followed by the imagined funeral and aftermath. a similar task is popularised by acceptance and commitment therapy, which involves vividly imagining one's own funeral, and writing one's own eulogy and a tombstone inscription (hayes and smith, 2005) . other exposure tasks may involve visiting places associated with death that the client has avoided, such as hospitals, nursing homes, cemeteries or funeral homes. reading obituaries online or in the newspaper may also offer valuable exposure opportunities, and clients should be encouraged to deliberately seek out those who have died around their own age (furer et al., 2007) . preparing one's will, or having discussions regarding end-of-life preferences, may also be considered as exposure tasks, and may serve the additional benefit of increasing the individual's sense of control over their death (furer et al., 2007; henderson, 1990) . books (e.g. when breath becomes air by paul kalanithi), films (e.g. blade runner, up), television shows (e.g. after life) and music (e.g. all things must pass by george harrison) related to death may all offer valuable and powerful opportunities for exposure, in addition to helping to normalise death. two thousand years ago, the stoic philosophers of ancient greece observed that 'it is not things themselves that trouble people, but their opinions about things' (epictetus, 2018, p. 11 ). this principle lies at the heart of both stoic philosophy (which emphasised the need to accept death as a universal event outside of our control) and cbt. all of us hold an array of beliefs surrounding death, which may fluctuate between being adaptive (e.g. the belief that we would ultimately cope with the death of a loved one) or maladaptive (e.g. the belief that dying will inherently involve pain and suffering). beliefs of this latter type will understandably cause distress for many individuals, and should be explicitly identified and challenged in therapy. for example, in the context of covid-19, the distress of some individuals will be grounded on over-estimating the probability of death from the virus; over-estimates of the fatality risk are commonplace (newton-john et al., 2020) . however, while standard treatments for anxiety may often involve disproving the client's probability estimates (kirk and rouf, 2004) , this is not recommended in treatments targeting death anxiety. disproving the individual's estimate of dying from any one particular cause (e.g. falling to one's death, dying in a plane crash, or succumbing to covid-19) only serves to address the proximal threat, and will probably do little to address their fear of their own inevitable death, from one cause or another. as such, it is central instead to focus on addressing the cost of death, rather than merely the probability. clients should be guided to cultivating an attitude of 'neutral acceptance' towards death; that is, an acceptance of death as a universal fact outside of one's control, and therefore neither good nor bad (wong et al., 1994) . standard cognitive challenging techniques can also be used to challenge unrealistic beliefs surrounding death. for example, for individuals fearing pain associated with dying, corrective information may be provided in the form of information from palliative care, and research indicating that dying is less unpleasant than people typically imagine. notably, theoretical orientations outside of standard cbt may also prove valuable in shifting clients' attitudes towards death. approaches from existential psychotherapy may be particularly relevant, and yalom (1980) outlines many relevant treatment recommendations from an existential lens. for example, for clients who express anxiety surrounding the concept of nonexistence, yalom (2008) recommends the use of the stoic 'symmetry' argument, which proposes that humans have already experienced non-existence, that is, prior to their birth. that is, death 'returns us to that peace in which we reposed before we were born. if someone pities the dead, let him also pity those not yet born' (seneca, 2018) . these clients may also be encouraged to foster gratitude for ever coming into existence at all, an idea persuasively expressed by richard dawkins, who notes that 'we are going to die, and that makes us the lucky ones', as we have 'won the lottery of birth against all odds' (dawkins, 1998, p. 1) . in order to help build identification with this idea, one exercise may involve estimating the likelihood of one's existence, by calculating the probability of one's parents ever meeting, followed by grandparents, and so forth (menzies, 2012) , in order to help the client focus on the incredible unlikelihood of their own dna sequence ever existing at all, rather than focusing on the tragedy of their own impermanence. the recent covid-19 pandemic has caused an understandable surge in anxiety across the globe. much of the behavioural response to covid-19 can be understood through the lens of terror management theory, which argues that death anxiety drives much of human behaviour (greenberg, 2012) . from this perspective, reminders of death (of which there are many in the current pandemic), produce increases in attempts to avoid a physical death (such as by wearing protective gear or self-isolating) or ensure a symbolic immortality (such as by bolstering one's cultural worldviews, and aggressing against those that threaten them). death anxiety, which has recently been proposed to be a transdiagnostic construct (iverach et al., 2014) , appears to be more relevant now than ever before. in addition to predicting anxiety related to covid-19 (newton-john et al., 2020) , fear of death has also been shown to play a causal role across a number of mental health conditions (menzies and dar-nimrod, 2017; strachan et al., 2007) . given this, current standard treatments for mental health conditions may benefit from addressing death anxiety directly, in order to prevent the 'revolving door' often seen in mental health services (iverach et al., 2014, p. 590) . fortunately, cbt has been demonstrated to produce significant reductions in death anxiety, with exposure appearing to be particularly effective (menzies et al., 2018) . complementing current treatments with specific cbt techniques addressing fears of death may help to ensure the best long-term outcomes for clients, and protect the individual from future disorders. however, further research is needed to examine whether treating death anxiety will in fact reduce the likelihood of future mental health problems. acknowledgements. none. financial support. none. conflicts of interest. the authors declare no conflicts of interest. (1) increasing evidence suggests that death anxiety is a key transdiagnostic construct, and may contribute to various mental health conditions. (2) standard treatments for a variety of disorders may need to be supplemented with specific treatment targeting death anxiety. (3) recent evidence demonstrates that death anxiety can be effectively reduced using cbt with a focus on exposure therapy. (4) we suggest a number of cbt treatment strategies, including cognitive reframing of unhelpful thoughts, and exposure tasks tailored to the feared situations, themes or images the individual avoids. (5) future research is needed to examine whether directly addressing death anxiety does indeed produce long-term improvement in symptoms, and prevent future disorders. brisbane, australia: australian academic press. the fear of covid-19 scale: development and initial validation ebola salience, deaththought accessibility, and worldview defense: a terror management theory perspective the denial of death supersize my identity: when thoughts of contracting swine flu boost one's patriotic identity two decades of terror manegement research: a meta-analysis of mortality salience research the relationships among psychological separation, the quality of attachment, separation anxiety and death anxiety a word of caution about many labs 4: if you fail to follow your preregistered plan, you may fail to find a real effect viewing death on television increases the appeal of advertsied products unweaving the rainbow racism and discrimination in covid-19 responses how to be free: an ancient guide to the stoic life (a. a. long, trans.) terror mismanagement: evidence that mortality salience exacerbates attentional bias in social anxiety treating health anxiety and fear of death: a practitioner's guide the novel coronavirus (covid-2019) outbreak: amplification of public health consequences by media exposure feeling and time: the phenomenology of mood disorders, depressive realism, and existential psychotherapy dying to be thin: the effects of mortality salience and body mass index on restricted eating among women terror management theory: from genesis to revelations terror management theory: implications for understanding prejudice, stereotyping, intergroup conflict, and political attitudes. social and personality psychology compass sympathy for the devil: evidence that reminding whites of their mortality promotes more favorable reactions to white racists assessing the terror management analysis of self-esteem: converging evidence of an anxiety-buffering function get out of your mind and into your life: the new acceptance and commitment therapy beyond the living will multidimensional treatment of fear of death death anxiety and its role in psychopathology: reviewing the status of a transdiagnostic construct the varieties of religious experience currencies as cultural symbols -an existential psychological perspective on reactions of germans toward the euro why are so many baby boomers in denial over the coronavirus? vogue multiculturalism, racism and infectious disease in the global city: the experience of the 2003 sars outbreak in toronto fears and phobias: part ii. welfare magazine specific phobias many labs 4: failure to replicate mortality salience effect with and without original author involvement death anxiety, perfectionism and disordered eating coronavirus anxiety scale: a brief mental health screener for covid-19 related anxiety the collett-lester fear of death scale: the original version and a revision self-control moderates the association between perceived severity of the coronavirus disease 2019 (covid-19) and mental health problems among the chinese public social reaction toward the 2019 novel coronavirus (covid-19). social health and behavior internet searches for unproven covid-19 therapies in the united states death anxiety as a predictor of posttraumatic stress levels among individuals with spinal cord injuries terror management and aggression: evidence that mortality salience motivates aggression against worldview-threatening others cognitive and behavioural procedures for the treatment of death anxiety impermanence and the human dilemma: observations across the ages death anxiety and its relationship with obsessive-compulsive disorder the relationship between death anxiety and severity of mental illnesses the effect of mortality salience on body scanning behaviours in mental illnesses creative approaches to treating the dread of death the effects of psychosocial interventions on death anxiety: a meta-analysis and systematic review of randomised controlled trials the dread of death and its role in psychopathology the role of death fears in obsessive-compulsive disorder psychological distress and covid-19: estimations of threat and the relationship with death anxiety hypochondriasis and fear of death investigation of death anxiety among depressive patients a dual-process model of defense against conscious and unconscious death-related thoughts: an extension of terror management theory a time to tan: proximal and distal effects of mortality salience on sun exposure intents stereotypes and terror management: evidence that mortality salience enhances stereotypic thinking and preferences how to die: an ancient guide to the end of life terror management and meaning: evidence that the opportunity to defend the worldview in response to mortality salience increases the meaningfulness of life in the mildly depressed body as the source of threat and fear of death in hypochondriasis and panic disorder terror mismanagement: evidence that mortality salience exacerbates phobic and compulsive behaviours the impact of mortality salience on reckless driving: a test of terror management mechanisms beliefs about self, life, and death: testing aspects of a comprehensive model of death anxiety and death attitudes ebola as an existential threat? experimentally-primed ebola reminders intensify national-security concerns among extrinsically religious individuals immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china death attitude profile-revised: a multidimensional measure of attitudes toward death coronavirus disease (covid-19): situation report -117 existential psychotherapy staring at the sun: overcoming the terror of death a systematic review of the psychometric properties of death anxiety self-report measures death anxiety in the time of covid-19: theoretical explanations and clinical implications. the cognitive behaviour therapist key: cord-012115-hpsxi9ay authors: archie, patrick; bruera, eduardo; cohen, lorenzo title: music-based interventions in palliative cancer care: a review of quantitative studies and neurobiological literature date: 2013-05-30 journal: support care cancer doi: 10.1007/s00520-013-1841-4 sha: doc_id: 12115 cord_uid: hpsxi9ay purpose: this study aimed to review quantitative literature pertaining to studies of music-based interventions in palliative cancer care and to review the neurobiological literature that may bare relevance to the findings from these studies. methods: a narrative review was performed, with particular emphasis on rcts, meta-analyses, and systematic reviews. the cochrane library, ovid, pubmed, cinahl plus, psycinfo, and proquest were searched for the subject headings music, music therapy, cancer, oncology, palliative care, pain, anxiety, depression, mood, quality of life, prevalence, neuroscience, functional imaging, endogenous opioids, gaba, 5ht, dopamine, and permutations of these same search terms. data for the review were comprised of articles published between 1970 and 2012. references of all the cited articles were also reviewed. results: available evidence suggests that music-based interventions may have a positive impact on pain, anxiety, mood disturbance, and quality of life in cancer patients. advances in neurobiology may provide insight into the potential mechanisms by which music impacts these outcomes. conclusions: more research is needed to determine what subpopulation of cancer patients is most likely to respond to music-based interventions, what interventions are most effective for individual outcomes, and what measurement parameters best gauge their effectiveness. by alleviating the physical and psychological symptoms associated with malignancy, palliative care serves a vital role in the multidisciplinary care of cancer patients. common symptoms such as pain, anxiety, and mood disturbance can be difficult to manage with standard pharmaceutical options and may significantly interfere with quality of life (qol) [1, 2] . the search for complimentary interventions that are both cost effective and associated with few side effects has led to an increased interest in the therapeutic use of music for cancer patients within the field of palliative care [3] [4] [5] [6] . this review summarizes findings from quantitative research literature. furthermore, it discusses challenges and opportunities associated with this emerging area of research and provides practical suggestions for future investigation. the interventions in this review are generally classified as either music medicine or music therapy. in "music medicine" interventions, patients listen to prerecorded music that is administered by healthcare staff and preselected by study investigators, who may or may not have any formal training in music therapy [7, 8] . in "music therapy" interventions, patients are offered prerecorded, live, and/or interactive music that is individualized by a trained music therapist [9, 10] . hence, the crucial distinction between music medicine (mm) and music therapy (mt) is that the former involves only a stimulus and response, and the latter involves a therapeutic relationship based on individualized assessment, treatment, and evaluation [7] . pain pain represents one of the most common symptoms affecting patients with advanced malignancy. one recent metaanalysis [11] pooled data from 52 studies (total n=19,985) and estimated pain to occur in 33 % of patients who had completed treatment with curative intent, 59 % of patients undergoing anticancer therapy, and 64 % of patients with advanced/metastatic/terminal disease. a subsequent meta-analysis [12] pooled data from 64 studies (total n=95,159), 34 of which reported pain prevalence in patients with all stages of cancer (including early disease), and 30 of which reported pain prevalence in patients with advanced cancer. the combined weighted mean prevalence of pain in the 14,961 patients with advanced cancer was estimated to be 75 %. multiple studies have demonstrated that music-based interventions may have a mild to moderate analgesic effect (table 1 ). five such randomized controlled trials (rcts) (total n=391) were analyzed in a 2011 cochrane review [13] . prerecorded music was provided perioperatively for 15 out of 30 breast cancer patients undergoing mastectomy [14] , during bone marrow biopsy for 29 out of 59 hematologic malignancy patients [15] , as a single 30-min session in 62 out of 126 adult patients with various malignancies [16] , during lumbar puncture in 20 out of 40 pediatric leukemia patients [17] , and as a single session with guided imagery in 65 out of 136 adult patients with various malignancies [18] . based on the combined results of these five studies, the authors classified music's analgesic effect as moderate, with a standardized mean difference (smd) of −0.59, (95 % ci from −0.92 to −0.27, p=0.0003). all five of the above studies reported pain by self-reported measurement scales. an earlier cochrane review examined the effect of music on analgesic requirements during a painful procedure (five studies), during a 2-h postoperative period (three studies), or during a 24-h postoperative period (five studies) [19] . although none of the included studies were limited to oncologic or palliative care settings, the 13 included studies (n= 1016) did show that exposure to music was associated with a decrease in opioid requirement, with a smd of −1.29 (95 % ci from −0.92 to −0.27, p=0.0062). these results were consistent with those from a separate meta-analysis [20] which studied the use of music vs. standard care in adult patients undergoing colonoscopy. this meta-analysis included three trials [21] [22] [23] in which music was provided to a total of 130 out of 261 patients. the patients who received music required 29.7 % less analgesia with meperidine, alfentanil, or pethidine (p=0.001) and 15 % less sedation with midazolam or propofol (p=0.055). finally, a single-arm study from 2006 [5] found that in 126 palliative care patients with pain (90 % of whom had cancer), mean self-reported pain scores decreased from 2.7 to 2.1 on a fivepoint vas after a single mt session (p<0.001). overall, these data (derived exclusively from mm-based approaches except for [5] ) support the use of music to decrease subjective pain and analgesic requirements in acute pain settings. however, more research is needed to investigate the analgesic efficacy of music for chronic pain, since cancer patients (particularly those in palliative care settings) frequently suffer from chronic pain (e.g., from bone metastases, visceral tumor growth, neuropathic pain associated with chemotherapy, etc.). in future studies investigating music-based interventions for chronic pain, careful consideration should be given to the frequency, duration, and type of interventions used (e.g., consideration of interventions not necessarily limited to mm). for many patients, the diagnosis of cancer can result in significant anxiety, which can interfere with sleep [24] , enjoyment of life [25] , interpersonal relationships [26] , and overall daily activities [27] . six studies using survey instruments found self-reported anxiety symptoms to be present in 19-48 % of cancer patients [1, 24, [28] [29] [30] [31] . in contrast, three studies using structured clinical interviews found dsm-ivdefined anxiety disorders (e.g., generalized anxiety disorder, panic disorder, and post-traumatic stress disorder) to be present in 7.6 to 18 % of cancer patients [24, 32, 33] . several studies have demonstrated that music-based interventions may have a mild to moderate anxiolytic effect ( table 2 ). seven such studies (six rcts and one controlled clinical trial (cct), total n=386) using self-report outcomes were analyzed in the 2011 cochrane review [13] . music was provided perioperatively for 15 out of 30 breast cancer patients undergoing mastectomy [14] , during invasive procedures for 20 out of 39 pediatric cancer patients [34] , directly prior to the administration of adjuvant chemotherapy for 30 out of 60 breast cancer patients [35] , during bone marrow biopsy for 29 out of 59 adults with hematologic malignancy [15] , during chemotherapy for 10 out of 20 adult cancer patients [36] , during radiation therapy for 19 out of 42 adult cancer patients [37] , and as a single 30-min session for 65 out of 136 adult cancer patients with pain [18] . based on the combined results of these seven studies, the smd on the 80-point state-trait anxiety inventory scale (stai-s) was −11.20 units (95 % ci −19.59 to −2.82, p=0.0088). these results were consistent [34] as a controlled clinical trial by the authors of the 2011 cochrane review [13] . note that the bufalini 2009 study [34] used mypas scores to measure anxiety in the patients, but only used stai-s scores to measure anxiety in the parents. since the stai-s scores in the parents (unlike the mypas scores in the patients) showed no significant difference, its inclusion in the pooled analysis with the other six trials would have tended to underestimate the effect of music on anxiety. [18] were clearly randomized, hence its classification as an rct by the authors of the 2011 cochrane review [13] . however, since its method of randomization was not entirely clear, it was excluded in the sensitivity analysis with those from four other rcts involving patients without cancer, in whom perioperative anxiety was significantly reduced by music-based interventions [38] [39] [40] [41] . one small but well-designed rct specifically examined the effectiveness of a single 20-40-min mt session in reducing anxiety for terminally ill patients [42] . although cancer was not an inclusion criterion, 24 out of 25 patients in the study had cancer, and all study participants were inpatients receiving palliative care services. based on the edmonton symptom assessment scale anxiety scores before and after the intervention, the mann-whitney test showed that anxiety was significantly reduced in the music group compared to the control group (p=0.005). overall, these data (derived from six studies using mm and two studies using mt) support the use of music to reduce anxiety in situations such as before/during invasive procedures, chemotherapy, and radiation therapy. relatively less is known about music's capacity to decrease the need for pharmacologic anxiolytics/sedatives/hypnotics. although one study in 327 patients undergoing elective surgery showed a greater decrease in preoperative stai-s scores with relaxing music than 0.05-0.1mg/kg of midazolam (p<0.001) [43] , the relevance of this finding to the oncologic and palliative care settings remains uncertain. furthermore, more research is needed to investigate the anxiolytic efficacy of music beyond the acute/situational anxiety setting, particularly for cancer patients in whom the recognition of disease progression and impending death may be particularly anxiety inducing [44, 45] . the period following diagnosis of cancer can be very emotional for many patients. patients with frequent depressive symptoms may develop a sustained disturbance of mood and may eventually meet criteria for a dsm-iv-defined affective disorder (e.g., major depressive disorder or dysthymic disorder). prevalence studies suggest that self-reported depressive symptoms in patients with cancer are common and perhaps more common in the terminal/advanced setting [46] [47] [48] [49] . four studies using survey instruments found depressive symptoms present in 53-74 % of cancer patients [46, [50] [51] [52] . a much more recent meta-analysis of 94 interview-based studies estimated the combined mean prevalence of major depressive disorder and dysthymic disorder in palliative and hematologic-oncologic settings [53] . from the 24 studies conducted in palliative care settings (total n=4,007), the combined mean prevalence of these two disorders was found to be 24.6 %. from the 70 studies conducted in hematology-oncology settings (total n = 10,071), combined mean prevalence was found to be 20.7 %. to place these numbers in context, the nimh estimates the combined prevalence of major depressive disorder and dysthymic disorder to be 8.2 % among us adults (two to three times lower than in cancer patients). while multiple studies have found that music-based interventions may have a positive impact on mood (table 3) , this has not necessarily been the case for depression. such a discrepancy may be at least partially explained by differences between methods used to assess mood disturbance versus those used to assess depression. for example, the commonly used profile of mood states (poms) uses six domains to calculate a total mood disturbance score: depression-dejection, tension-anxiety, anger-hostility, fatigue-inertia, confusion-bewilderment, and vigor-activity. the first five domains are weighted positively and the last domain is weighted negatively, such that a higher score indicates a greater disturbance of mood. henceforth, music could elicit improvement in mood via the five other domains but not in "depression/dejection." this difference in outcomes was well illustrated in a 2011 cochrane review [13] , which analyzed five trials examining the effect of music on depression (total n=468 patients). music was provided for 128 out of 182 adults with cancer receiving chemotherapy or radiation therapy [54] , 34 out of 60 adults with hematologic malignancy admitted for autologous sct [55] , 27 out of 48 adults with cancer undergoing radiation therapy [56] , 20 out of 42 women with metastatic breast cancer [57] , and 65 out of 136 adult cancer patients with pain [18] . the pooled estimate from these five trials did not find a statistically significant effect of music on depression (smd=−0.07, 95 % ci −0.40 to 0.27, p=0.69). however, the same metaanalysis analyzed three trials examining the effect of music on mood (total n=105), and the pooled estimate from these three studies did demonstrate a statistically significant effect (smd=0.42, 95 % ci 0.03 to 0.81, p=0.03). these three studies investigating the outcome of mood provided music to 8 out of 15 adults with cancer-related pain [58] , 34 out of 60 adults with hematologic malignancy admitted for autologous sct [55] , and 15 out of 30 children with neoplasms needing chemotherapy [59] . that cassileth's same study [55] showed no effect on depression, but did show an effect on mood, supports the idea that the difference between these two outcomes may be more than semantic. among the 123 palliative care patients with mood disturbance in the singlearm study of gallagher et al. in 2006 [5] , mean self-reported mood disturbance scores improved from 1.8 to 0.7 on a fivepoint vas after a single mt session (p<0.001). overall, the limited data available regarding the outcome of mood (derived from three studies using mt and one study using mm) suggest that music may have a mild positive impact on the mood of cancer patients. considering that the effects of music-based interventions on pain and anxiety have been most well demonstrated in acute settings, it may not be surprising that a single intervention (mm or mt based) may not show as much impact on mood disturbance, particularly chronically depressed mood. the availability of fast-acting pharmacologic analgesics and anxiolytics, versus [79] fmri was used to examine changes in neural activation due to painful thermal stimuli (delivered to the skin of the left hand through a peltier-based thermode at 46°c) in 8 healthy male subjects, who rated their pain levels using a visual analog scale two temporal phases of pain response were observed: early and late. during the early phase, increased signal was seen in reward regions such as the left anterior nucleus acccumbens (nac), the ventral tegmentum (vt), the periaqueductal gray (pag), the sublenticular extended amygdala (slea) of the basal forebrain, and the orbital gyrus. in the late response, decreased signal was seen in the left posterior nac, while increased signal was seen in classical pain regions such as the thalamus, s1, insula, and anterior cingulate gyrus blood et al., 1999 [110] pet was used to examine changes in regional cerebral blood flow (rcbf) related to emotional responses to music. ten musicians were exposed to 6 versions of a novel musical passage varying systematically in degree of dissonance subjective pleasantness and unpleasantness ratings were correlated with consonance and dissonance, respectively. increasing consonance was correlated with increasing activity in the orbitofrontal cortex, frontal polar cortex, and the subcallosal cingulate gyrus. increasing dissonance was correlated with increasing activity in the precuneus region and the right parahippocampal gyrus blood and zatorre, 2001 [97] pet was used to examine changes in rcbf related to "intensely pleasant emotional responses to music" manifesting as piloerective chills measured by electrodermal monitoring. ten musicians were exposed to self-selected music, control music, amplitude-matched noise, and silence. rcbf values were extracted from individual scans and plotted against chill intensity increasing chill intensity was correlated with increasing activity in the left ventral striatum (including the nac) and dorsomedial midbrain (including the pag), and decreasing activity in the right amygdala, left hippocampus, and ventral medial prefrontal cortex engel et al., 2009 [82] this article reviews findings from multiple neuroimaging studies using fmri, pet, and radioligand binding experiments to investigate anxiety in healthy subjects as well as patients with panic disorder, generalized anxiety disorder, social anxiety disorder, and specific phobias enhancement of activity in the amygdala was a very common finding. enhanced activity was also commonly found in the prefrontal cortex, insula, and the anterior cingulate cortex menon and levitin, 2005 [98] high-resolution fmri was used to examine changes in neural activation due to "passive music listening." fourteen non-musicians were exposed to 10 intact samples of music and 10 scrambled samples for control stimuli. hemodynamic changes were subject to statistical, functional connectivity, and effective connectivity analyses passive listening to music resulted in significant activation of multiple specific structures including the nac, the vta, and the hypothalamus. functional connectivity analysis showed that responses in the nac and the vta were highly correlated, "suggesting an association between dopamine release and nac response to pleasant music" nestler and carlezon, 2005 [85] this article reviews the mesolimbic dopamine reward circuit in depression. data from animal studies and some human studies are discussed the authors discuss how abnormalities in the vta and nac may be related to depressive symptoms such as anhedonia, reduced motivation, decreased energy level, etc. roles of specific proteins, such as the transcription factor camp response element binding protein (creb) and the endogenous kappa-opioid receptor agonist dynorphin are reviewed pereira, 2011 [106] fmri was used to investigate blood oxygenation level dependence (bold) responses to musical stimuli that varied according to participant familiarity and preference. fourteen non-musicians underwent a listening test which consisted of 15 s excerpts from 110 pop/rock songs which they rated by degree of familiarity and preference. during fmri, the participants were then exposed to 48 excerpts, with 12 excerpts from each of the following categories based upon the listening test results: familiar liked, familiar unliked, unfamiliar liked, and unfamiliar unliked familiarity was found to have a greater impact than preference in triggering bold responses in the following emotion-related regions: putamen, amygdala, nac, anterior cingulate cortex, and thalamus receptors. information about the dynamics of dopamine release over time was collected using fmri. eight participants were exposed to self-selected pleasurable musical excerpts versus neutral musical excerpts. electrodermal skin conductance was used to measure piloerective chills while participants provided subjective feedback about degree of listening pleasure compared to neutral musical excerpts, pleasurable musical stimuli (concurrently measured by chill intensity and subjective participant ratings) resulted in distinct striatal responses detectable by pet and fmri. ligand-based pet data revealed increased endogenous dopamine transmission, as indicated by decreased [ 11 c] raclopride binding potential in the right nac. fmri showed increased bold response in the right nac during peak pleasure experience epochs the unavailability of any fast-acting pharmacologic antidepressant, may point toward potentially important neurobiological differences underlying these symptoms. with this in mind, particular consideration should be given to the frequency and duration (as well as the type) of interventions in future studies investigating the impact of music on mood in cancer patients. although there may be less prevalence data measuring overall qol impairment in cancer patients (relative to pain, anxiety, and depression), the available data suggest that cancer is indeed associated with impaired qol compared to the normal population [60] [61] [62] . this association could be expected for a number of reasons: first, because pain, anxiety, and depression are frequently incorporated into the tools used to measure hr-qol in cancer patients; secondly, because all three of these symptoms have been shown to commonly affect patients with cancer [63] ; and finally, because multiple studies in patients with multiple types of cancer have demonstrated independent associations between hr-qol impairment and pain [64] [65] [66] [67] [68] , anxiety [69] [70] [71] , and depression [72] [73] [74] . although the impact of music-based interventions on qol has not been as extensively studied as pain, anxiety, or mood disturbance, four rcts analyzed in the 2011 cochrane review [13] compared the impact of musicbased interventions to standard care on qol scores (table 4 ). clearly, qol represents a more complex and multi-faceted outcome than pain, anxiety, or depression, and the comparison of results from these four studies was made even more complex by the fact that they all used different qol assessment tools. in one of the four studies [57] , pretest differences were too large for the results to be included in the pooled estimate. through the other three trials, music was offered to 4 of 8 adults with cancer [75] , 40 out of 80 adults with terminal cancer [76] , and 124 out of 260 cancer patients receiving chemotherapy [77] . when the results from these three trials were subject to meta-analysis, a heterogeneous, nonsignificant effect was found (smd=2.01, 95 % ci −0.09 to 4.11, p= 0.06). paradoxically, this nonsignificance actually resulted from a much larger beneficial effect reported in the study by zhong [77] than that reported in the studies by burns [75] and hilliard [76] . when the results from the burns and hilliard studies were subject to meta-analysis (n=88), this resulted in a homogenous and significant effect of mt on qol (smd=1.02, 95 %ci 0.58 to 1.47, p=0.00001). one interesting aspect of the hilliard study was that even as the physical health of the patients in the music group declined, qol scores improved. this was not the case in the control group, in whom qol scores worsened as their physical health declined [76] . clearly, more research is needed to investigate the impact of music on qol. given the crucial importance of this fig. 1 a sagittal view of neuroanatomic regions affected by music (and implicated in the pathophysiology of pain, anxiety, and/or depression). b inferior view of neuroanatomic regions affected by music (and implicated in the pathophysiology of pain, anxiety, and/or depression) outcome to cancer patients in palliative care settings, future studies investigating the effect of music-based interventions on pain, anxiety, or mood disturbance in this patient population should incorporate qol measurements into their outcome assessment. previous speculations regarding the potential mechanisms of music-based interventions may have drastically oversimplified an extremely complex set of possible neurobiological processes [78] . many investigators have proposed that music may compete with noxious stimuli and thereby close neurological gates of pain signal transmission, or that it may distract patients from threats that cause them to feel anxious, and/or that it may promote a sense of well-being in patients with an otherwise depressed mood. while these may all be valid theories, advances in neuroscience, and functional neuroimaging studies in particular, are providing dramatic new insights into the findings from clinical trials involving music-based interventions ( table 5) . multiple studies have explored changes in activity within the brains of healthy, asymptomatic adults upon exposure to music. broadly speaking, functional imaging data have shown that music modulates the activity of multiple limbic and paralimbic brain structures, but especially the ventral striatum (including the nucleus accumbens), the dorsomedial midbrain (including the ventral tegmental area and periaqueductal gray), the amygdala, and the hippocampus (fig. 1a, b) . this particular neuroanatomic distribution is striking for at least two reasons. the first is that functional abnormalities in these same structures are implicated in the pathophysiology of pain [79] [80] [81] , anxiety [82] [83] [84] , and depression [85] [86] [87] . the second is that these same structures are known to be densely populated by receptors of ligands associated with pain, anxiety, and depression-namely, endogenous opioids [88, 89] , gaba [90, 91] , and dopamine [92, 93] . listening to music has long been known to evoke strong emotional responses which can sometimes be accompanied by physical manifestations, e.g., piloerection, more commonly known as "goosebumps" or "chills" [94, 95] . the suppression of this response with the mu-opioid receptor agonist nalaxolone provided early evidence that endogenous opioid activity might underlie pleasurable responses to music [96] . positron emission tomography experiments subsequently showed that piloerection in response to music may be associated with increased regional cerebral blood flow to the ventral striatum and the dorsomedial midbrain but decreased regional cerebral blood flow (rcbf) to the hippocampus and amygdala [97] . even in the absence of piloerective responses, fmri evidence suggested that consonant musical excerpts may increase activity in the ventral striatum and the anterior insula [98, 99] , while dissonant excerpts may increase activity in the amygdala and hippocampus [99] . data collected from [ 11 c] raclopride pet demonstrated that intensely pleasurable responses to music may be associated with dopamine release in the striatal system [100] . this dopaminergic activity in the nac following exposure to music (and other pleasurable stimuli, e.g., sex, food, and drugs of abuse) may itself be modulated by endogenous opioids [101] . furthermore, evidence from animal models suggests that opioid efferent projections from the nac may directly mediate reward-related behavior [102] . within the dorsomedial midbrain (which was found to receive increased rcbf during highly pleasurable musical experiences as shown in [97] ), the substructure known as the periaqueductal gray has been shown to be densely populated with endogenous opioid receptors and may be involved in both opioid-mediated reward [103] and analgesia [79, 104] . preliminary research suggests that the action of endogenous opioids in the pag may be influenced by the hormone oxytocin [105] ; the blood concentrations of which was found to be increased (along with subjective relaxation) in perioperative patients exposed to soothing music [106] . although multiple functional imaging studies have shown music to modulate the activity of the amygdala [97, 107] , and multiple functional imaging studies have demonstrated an association between anxiety and enhanced amygdalar activity [82, 83, 108, 109] , no radioligand binding experiments have specifically investigated the effect of music on gamma amino-butyric acid activity in the brain. with regard to mood disturbance, it is worth noting that music has been shown to modulate the activity of the subcallosal cingulate region [107, 110] , an area which has been shown to have decreased rcbf in patients with depression [111] . furthermore, deep brain stimulation of the subcallosal cingulate region has been shown to be an effective treatment for severe depression [86] . finally, platelet concentrations of serotonin, which may correlate with neuronal concentrations of serotonin [112, 113] , were found to be increased in humans exposed to euphonic music, but decreased in humans exposed to cacophonic music [114] . overall, these advances in neurobiology suggest that music may affect specific neuronal pathways that are implicated in the pathophysiology of pain, anxiety, and depression. thus, future neurobiological studies may provide objective insight into the mechanisms by which music may affect these subjective symptoms that commonly afflict patients with cancer. in 2002, the who approved the following definition of palliative care: "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual" [115] . in the future, music-based interventions may prove to become valuable tools in the "relief of suffering" of cancer patients. specifically, music may help alleviate pain, anxiety, and mood disturbance, all of which commonly occur in cancer, and all of which may be associated with impaired qol. the potential of music to reduce the need for analgesics and/or anxiolytics, even if only by a small amount, may still have major clinical implications, especially given the frequency with which advanced age and hepato-renal dysfunction coexist in the palliative cancer care population (and hence their predisposition to pharmacologic toxicity). furthermore, when the only pharmacologic agents available for mood disturbance take weeks to months to take effect, interventions that provide more immediate benefits, even if modest, may warrant further investigation. it is not difficult to imagine how, for cancer patients unfamiliar with the standard inpatient healthcare environment, the hospital setting could be associated with unexpected pain (e.g., from repeated injections, blood draws, and other invasive procedures), anxiety (e.g., from loud equipment alarms and time-constrained conversations regarding prognosis often clouded by medical jargon), and even depression (e.g., related to the existential issues of having a life-threatening illness, limited social interaction, frequently interrupted sleep, etc.). the capacity of music to restore a sense of familiarity, and the therapeutic value of such a reassuring stimulus (regardless of where a patient may be in his or her disease trajectory), may be underestimated. such reassuring familiarity could be provided in the form of a playlist of favorite songs on a portable mp3 player with headphones or even through melodic arrangement by a live music therapist that actually incorporates tones from the surrounding environment [116] . it should not necessarily be assumed that the benefits of music are limited to the relief of symptoms; that is to say, that music merely counteracts the negative consequences of disease (fig. 2) . the need for beauty (and for some, spiritual solace) may be particularly great toward the end of life for many patients. in this respect, music may exceed where standard pharmacologic means fall short. many qualitative studies support both the potential symptomalleviating and wellness-promoting effects of music [3, 10, [117] [118] [119] [120] [121] [122] [123] [124] [125] . however, quantitative data in these areas still remain limited. in the absence of more rcts with larger sample sizes, meta-analyses [13, 20, 126] can provide useful quantitative assessments of impact. however, controlling for variation in study design, study population, specific intervention(s), and outcome assessment methods, presents enormous challenges. for example, different music therapists can introduce variability in outcomes, even when the same specific interventions are used [127] . the data presented in the individual trials and the meta-analyses discussed in this review should therefore be considered preliminary and interpreted with caution. the statistical quality of the data in question remains diminished by high risk of bias, which almost invariably arises from the inherent difficulties associated with conventional blinding in music-based intervention studies. furthermore, without reliable biomarkers for pain, anxiety, and depression, defining the "gold standard" in quantitative assessment of these outcomes remains formidable. fortunately, the cost of music-based interventions remains relatively low [128] , and breakthroughs in the field of neurobiology continue to advance our understanding of the anatomical and biochemical basis of how music works in the brain, and why symptoms such as pain, anxiety, and mood disturbance might be influenced. further investigation is warranted to determine (1) if certain subpopulations of cancer patients are more likely to respond to music-based interventions than others, (2) what interventions are most effective for such responsive patients, and (3) what measurement parameters best gauge their effectiveness. greater collaboration between the fields of music therapy and music neuroscience may accelerate the pursuit of these objectives. finally, given the emerging evidence that earlier involvement of palliative care may improve outcomes in certain cancer patients [129] , and that psychological stress may be linked to up-regulation of inflammatory processes that promote tumor growth and angiogenesis [130] [131] [132] [133] , it follows that research into the potential of music to specifically promote relaxation and reduce stress [134] , perhaps earlier in cancer's trajectory, may also be warranted. assessing the independent contribution to quality of life from anxiety and depression in patients with advanced cancer the impact of pain on quality of life. a decade of research objectivist and constructivist music therapy research in oncology and palliative care perspectives on music therapy in adult cancer care: a hermeneutic study the clinical effects of music therapy in palliative medicine music therapy in supportive cancer care music therapy: models and interventions music therapy and medicine: theoretical and clinical applications defining music therapy music therapy in palliative care prevalence of pain in patients with cancer: a systematic review of the past 40 years cancer pain epidemiology music interventions for improving psychological and physical outcomes in cancer patients perioperative music and its effects on anxiety, hemodynamics, and pain in women undergoing mastectomy music for patients with hematological malignancies undergoing bone marrow biopsy: a randomized controlled study of anxiety, perceived pain, and patient satisfaction music therapy to reduce pain and anxiety in children with cancer undergoing lumbar puncture: a randomized clinical trial influence of music therapy on anxiety, depression and pain of cancer patients music for pain relief music in the endoscopy suite: a meta-analysis of randomized controlled studies the effect of self-selected music during colonoscopy on anxiety, heart rate, and blood pressure relaxation music decreases the dose of patient-controlled sedation during colonoscopy: a prospective randomized controlled trial improved procedure of colonoscopy under accompanying music therapy anxiety disorders in cancer patients: their nature, associations, and relation to quality of life psychological variables and cancer pain psychological distress of patients with advanced cancer: influence and contribution of pain severity and pain interference effect of cancer pain on performance status, mood states, and level of hope among taiwanese cancer patients study of anxiety disorder and depression in long-term survivors of testicular cancer mixed anxiety/depression symptoms in a large cancer cohort: prevalence by cancer type anxiety in terminally ill cancer patients are anxiety and depressed mood related to physical symptom burden? a study in hospitalized advanced cancer patients anxiety disorders in advanced cancer patients depression and anxiety disorders in palliative cancer care role of interactive music in oncological pediatric patients undergoing painful procedures effectiveness of music therapy for anxiety reduction in women with breast cancer in chemotherapy treatment reducing treatment-related anxiety in cancer patients: comparison of psychological interventions music as a therapeutic intervention for anxiety in patients receiving radiation therapy the effect of music on preoperative anxiety in day surgery a comparison of intraoperative or postoperative exposure to music-a controlled trial of the effects on postoperative pain stress reduction and analgesia in patients exposed to calming music postoperatively: a randomized controlled trial sedative music reduces anxiety and pain during chair rest after open-heart surgery the effect of music therapy on anxiety in patients who are terminally ill relaxing music as pre-medication before surgery: a randomised controlled trial the efficacy of audiotapes in promoting psychological well-being in cancer patients: a randomised, controlled trial anxiety disorders. in: holland j (ed) psycho-oncology psychiatric consultation in fatal illness a prevalence study of depression in a cancer hospital population the prevalence of psychiatric disorders among cancer patients prevalence of depression in the terminally ill: effects of diagnostic criteria and symptom threshold judgements psychiatric symptomatology among hospitalized cancer patients cancer and psyche emotional reactions to having cancer prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies music therapy in treatment of cancer patients music therapy for mood disturbance during hospitalization for autologous stem cell transplantation use of preferred music to reduce emotional distress and symptom activity during radiation therapy effects of a music therapy intervention on quality of life and distress in women with metastatic breast cancer salt lake city 59. duocastella ac (1999) effect of music on children with cancer the quality of life of cancer patients: a review of the literature general population and cancer patient norms for the functional assessment of cancer therapy-general (fact-g) health-related quality of life in longterm head and neck cancer survivors: a comparison with general population norms ed) handbook of pain and palliative care: biobehavioral approaches for the life course defining the content domain of quality of life for cancer patients with pain the effects of pain severity on health-related quality of life treatment of hormone-refractory prostate cancer with docetaxel or mitoxantrone: relationships between prostate-specific antigen, pain, and quality of life response and survival in the tax-327 study cancer-related pain: a pan-european survey of prevalence, treatment, and patient attitudes the symptom cluster of fatigue, pain, anxiety, and depression and the effect on the quality of life of women receiving treatment for breast cancer: a multicenter study anxiety and depression in cancer patients: relation between the hospital anxiety and depression scale and the european organization for research and treatment of cancer core quality of life questionnaire quality of life and symptoms of anxiety and depression of patients receiving cancer chemotherapy: longitudinal study anxiety, depression, traumatic stress and quality of life in colorectal cancer after different treatments: a study with portuguese patients and their partners a study of quality of life in cancer patients receiving palliative chemotherapy depressive symptoms and quality of life in home-care-assisted cancer patients the association of depression and anxiety with health-related quality of life in cancer patients with depression and/or pain the effect of the bonny method of guided imagery and music on the mood and life quality of cancer patients the effects of music therapy on the quality and length of life of people diagnosed with terminal cancer effect of music therapy and relaxation inner image on quality of life in cancer patients receiving chemotherapy a neuroscientific perspective on music therapy reward circuitry activation by noxious thermal stimuli new perspectives in eeg/meg brain mapping and pet/fmri neuroimaging of human pain descending control of pain neuroimaging in anxiety disorders increased amygdala and insula activation during emotion processing in anxiety-prone subjects the neurobiology of anxiety disorders: brain imaging, genetics, and psychoneuroendocrinology the mesolimbic dopamine reward circuit in depression limbic-cortical dysregulation: a proposed model of depression glucose metabolism in the amygdala in depression: relationship to diagnostic subtype and plasma cortisol levels endogenous opioids: their physiological role and receptors endogenous opioids: biology and function immunocytochemical localization of gababr1 receptor subunits in the basolateral amygdala the neuropsychology of anxiety: an enquiry into the functions of the septo-hippocampal system localization of d1 and d2 dopamine receptors in brain with subtype-specific antibodies dopamine, depression and antidepressants the emotional sources of "chills" induced by music event-related skin conductance responses to musical emotions in humans thrills in response to music and other stimuli intensely pleasurable responses to music correlate with activity in brain regions implicated in reward and emotion the rewards of music listening: response and physiological connectivity of the mesolimbic system investigating emotion with music: an fmri study anatomically distinct dopamine release during anticipation and experience of peak emotion to music neuropharmacological mechanisms of drug reward: beyond dopamine in the nucleus accumbens cannabinoid transmission and reward-related events the development of a conditioned place preference to morphine: effects of micro-injections into various cns sites opioid supraspinal analgesic synergy between the amygdala and periaqueductal gray in rats oxytocin in the periaqueductal gray participates in pain modulation in the rat by influencing endogenous opiate peptides soothing music can increase oxytocin levels during bed rest after open-heart surgery: a randomised control trial music and emotions in the brain: familiarity matters functional neuroanatomy of emotion: a meta-analysis of emotion activation studies in pet and fmri human amygdala responses during presentation of happy and neutral faces: correlations with state anxiety emotional responses to pleasant and unpleasant music correlate with activity in paralimbic brain regions subgenual prefrontal cortex abnormalities in mood disorders the human platelet: a diagnostic research tool for the study of biogenic amines in psychiatric and neurologic disorders platelets as models for monoaminergic neurons changes of the neurotransmitter serotonin but not of hormones during short time music perception treating stress, speech disorders with music the use of music therapy to address the suffering in advanced cancer pain music and healing in cancer care: a survey of supportive care providers music therapy in pain and symptom management multidisciplinary perspectives of music therapy in adult palliative care the role of the music therapist on the hospice/ palliative care team music therapy in palliative/hospice care the use of music therapy in meeting the multidimensional needs of hospice patients and families music therapy at the end of life music therapy with patients undergoing radiation and chemotherapy. lonely waters. sobell music therapy for end-of-life care interactive music therapy as a treatment for preoperative anxiety in children: a randomized controlled trial a cost-benefit analysis of music therapy in a home hospice early palliative care for patients with metastatic nonsmall-cell lung cancer chronic stress promotes tumor growth and angiogenesis in a mouse model of ovarian carcinoma depressive symptoms and cortisol rhythmicity predict survival in patients with renal cell carcinoma: role of inflammatory signaling impact of stress on cancer metastasis neuroendocrine modulation of cancer progression music and stress acknowledgments thanks to david aten of mdacc medical key: cord-289498-6hf3axps authors: tull, matthew t.; barbano, anna c.; scamaldo, kayla m.; richmond, julia r.; edmonds, keith a.; rose, jason p.; gratz, kim l. title: the prospective influence of covid-19 affective risk assessments and intolerance of uncertainty on later dimensions of health anxiety date: 2020-08-12 journal: j anxiety disord doi: 10.1016/j.janxdis.2020.102290 sha: doc_id: 289498 cord_uid: 6hf3axps the covid-19 pandemic is likely to increase risk for the development of health anxiety. given that elevated health anxiety can contribute to maladaptive health behaviors, there is a need to identify individual difference factors that may increase health anxiety risk. this study examined the unique and interactive relations of covid-19 affective risk assessments (worry about risk for contracting/dying from covid-19) and intolerance of uncertainty to later health anxiety dimensions. a u.s. community sample of 364 participants completed online self-report measures at a baseline assessment (time 1) and one month later (time 2). time 1 intolerance of uncertainty was uniquely associated with the time 2 health anxiety dimension of body vigilance. time 1 affective risk assessments and intolerance of uncertainty were uniquely associated with later perceived likelihood that an illness would be acquired and anticipated negative consequences of an illness. the latter finding was qualified by a significant interaction, such that affective risk assessments were positively associated with anticipated negative consequences of having an illness only among participants with mean and low levels of intolerance of uncertainty. results speak to the relevance of different risk factors for health anxiety during the covid-19 pandemic and highlight targets for reducing health anxiety risk. beginning in late 2019, a severe acute respiratory syndrome coronavirus began to rapidly spread across the globe, becoming an unprecedented public health event (centers for disease control and prevention [cdc] , 2020; world health organization [who], 2020b). on january 30, 2020, the who announced that covid-19 was a public health emergency of international concern, and in march 2020, pandemic status was reached. currently, over 14 million confirmed cases of covid-19 have been reported worldwide, and over 600,000 people have died from the disease (cdc, 2020; who, 2020b) . within the u.s. alone, there have been over 3.7 million confirmed cases of covid-19, with over 140,000 mortalities attributed to the virus (cdc, 2020) . 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, khan, kazmi, bashir, & siddique, 2020) , governments worldwide have had to implement extraordinary physical distancing interventions in an attempt to slow the spread of the virus, reduce covid-19 mortality rates, and minimize the burden on the health care system. within the u.s., implementation of stay-at-home orders began in mid-march 2020, with most states having such orders in place by early april 2020 (mervosh, lu, & swales, 2020) . although no vaccine or established treatments for covid-19 are currently available, strict stay-at-home orders within the u.s. are beginning to ease. specifically, all 50 states have taken steps to reopen businesses throughout may 2020, with most moving to rescind stringent stay-at-home orders in sensations (e.g., muscle soreness, shortness of breath, sore throat) as an indication of illness, infection, or some other threat to physical health taylor & asmundson, 2004) . at high levels, health anxiety may contribute to increased body vigilance, catastrophic misinterpretation of bodily sensations, and illness behavior (e.g., reassurance seeking on the internet, frequent and unnecessary visits to a doctor or emergency room, excessive collection of personal protective equipment; asmundson et al., 2010; asmundson & taylor, 2002b; taylor & asmundson, 2004) . in the context of a pandemic, individuals with elevated health anxiety may be particularly likely to experience an increase in awareness and catastrophic misinterpretation of bodily sensations that result in maladaptive safety-seeking behavior (asmundson & taylor, 2020b; taylor, 2019) . for example, a recent study found that health anxiety was associated with covid-19 related anxiety and cyberchondria (i.e., the repeated carrying out of health-related internet searches in an attempt to obtain reassurance or reduce health-related anxiety ; jungmann & witthöft, 2002) . given the potential negative consequences associated with health anxietyrelated behaviors in the context of a pandemic (e.g., increased doctor visits may overwhelm the health care system, stockpiling of personal protective equipment may decrease or eliminate its availability to others in need), there is a need to identify individual difference factors that may increase risk for health anxiety in the context of the current covid-19 pandemic. one such risk factor for health anxiety may be an individual's perceived likelihood of becoming infected with or dying from covid-19. past research has found that individuals with elevated healthy anxiety are more likely to cognitively overestimate their risk for illness (hadjistavropoulos, craig, & hadjistavropoulos, 1998; marcus & church, 2003) . however, health behavior models are increasingly highlighting the relevance of affect-laden risk or vulnerability assessments (vs. more cognitively-based assessments where individuals j o u r n a l p r e -p r o o f health anxiety during covid-19 6 deliberately estimate the probability or likelihood of a particular health event) to psychological outcomes, emphasizing the relative importance of the extent to which individuals feel that they are at risk for or worry about certain health events (i.e., affective risk assessments; loewenstein, weber, hsee, & welch, 2001; janssen, van osch, lechner, candel, & de vries, 2012; janssen, waters, van osch, lechner, & de vries, 2012) . for example, janssen, van osch, et al. (2012) found that affective risk assessments about cancer risk were more strongly related to cancerspecific health anxiety than cognitive risk assessments. likewise, affective risk assessments have been found to be more highly related to behavioral intentions and health behaviors than cognitive risk assessments (janssen, van osch, et al., 2012; janssen, waters, et al., 2012) . given evidence that worry states may increase attentional bias to threatening stimuli (mogg & bradley, 2005; mogg, mathews, & eysenck, 1992) , individuals who experience greater worry about their perceived risk for covid-19 infection and mortality may be more likely to notice and attend to bodily sensations that could be indicative of covid-19 infection (e.g., muscle pain, shortness of breath, cough, chills), resulting in increased health anxiety over time. given the unpredictability and variability associated with covid-19 symptom presentations, as well as the potentially long incubation period associated with this virus (i.e., symptoms may present themselves anywhere from 2 to 14 days following exposure), the association between covid-19 affective risk assessments and health anxiety may be particularly strong for individuals with high intolerance of uncertainty. intolerance of uncertainty is broadly defined as a cognitive and emotional tendency to react negatively to uncertain situations or unpredictable future events (freeston, rhéaume, letarte, dugas, & ladouceur, 1994) , and has been identified as a key factor in the development and maintenance of problematic worry (buhr & dugas, 2006; dugas, freeston, & ladouceur, 1997; freeston et al., 1994) . in addition to j o u r n a l p r e -p r o o f health anxiety during covid-19 7 demonstrating a relationship with numerous anxiety disorders (boelen & reijntjes, 2009; carleton et al., 2012; gentes & ruscio, 2011; holaway, heimberg, & coles, 2006) , intolerance of uncertainty has been associated with increased health anxiety and catastrophic health appraisals. inhibitory facets of intolerance of uncertainty (e.g., diminished functioning in the face of uncertainty) have been shown to predict health anxiety among medically healthy communitydwelling adults (fergus & bardeen, 2013) . further, intolerance of uncertainty has been found to moderate the relationship between the frequency of internet searches for health information and health anxiety among medically healthy adults in the community (fergus, 2013) . research has also found that intolerance of uncertainty moderates the relationship between catastrophic health appraisals and health anxiety among medically healthy college students, with this relationship emerging as significant only among individuals with high intolerance of uncertainty (fergus & valentiner, 2011) . more recently, asmundson and taylor (2020a) identified intolerance of uncertainty as a potential individual difference factor that may increase risk for covid-19 related anxiety. in the context of the covid-19 pandemic, high intolerance of uncertainty may further exacerbate worry and negative affect associated with perceived risk for covid-19 infection and mortality, contributing to heightened health anxiety. moreover, given that intolerance of uncertainty may increase the likelihood that ambiguous experiences are perceived as threatening (byrne, hunt, & chang, 2015) , high covid-19 affective risk perceptions may be more likely to prompt catastrophic misinterpretations of benign bodily sensations as an indication of illness. the goals of the present study were to examine the prospective relations of covid-19 affective risk assessments and intolerance of uncertainty to health anxiety dimensions one month j o u r n a l p r e -p r o o f later, as well as the moderating role of intolerance of uncertainty in the relations of covid-19 affective risk perceptions to later health anxiety. we predicted that both covid-19 affective risk perceptions and intolerance of uncertainty would predict later health anxiety dimensions, controlling for health anxiety at baseline. further, we predicted that the relationship between covid-19 affective risk assessments and health anxiety would be strongest among individuals with high (vs. mean or low) levels of intolerance of uncertainty. participants were a nationwide community sample of 364 adults from 44 states in the u.s. who completed a prospective online study of health and coping in response to through an internet-based platform (amazon's mechanical turk; mturk). participants completed an initial assessment (time 1) from march 27, 2020 through april 5, 2020, and a follow-up assessment (time 2) approximately one month later between april 27, 2020 and may 21, 2020. the study was posted to mturk via cloudresearch (cloudresearch.com), an online crowdsourcing platform connected to mturk that allows additional data collection features (e.g., creating selection criteria; chandler, rosenzweig, moss, robinson, & litman, 2019; litman, robinson, & abberbock, 2017) . 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. data provided by mturk-recruited participants have been found to be as reliable as data collected through more traditional methods (buhrmester, kwang, & gosling, 2011) . likewise, mturk-recruited participants have been found to perform better on attention check items than college student samples (hauser & schwarz, 2016) and comparably to participants completing the same tasks in a laboratory setting (casler, bickel, & j o u r n a l p r e -p r o o f health anxiety during covid-19 9 hackett, 2013). studies also show that mturk samples have the advantage of being more diverse than other internet-recruited or college student samples (buhrmester et al., 2011; casler et al., 2013) . for the present study, inclusion criteria consisted of: (1) u.s. resident, (2) at least a 95% approval rating as an mturk worker, (3) participants (51.4% women; 47.5% men; 0.5% non-binary; 0.3% transgender, 0.3% other) ranged in age from 20 to 74 years (m = 41.45, sd = 12.02) at the initial assessment. all states in the u.s. were represented, with the exception of delaware, nebraska, new hampshire, north dakota, vermont, and west virginia. the most frequently endorsed states of residence were florida (11.3%), california (9.1%), pennsylvania (6.3%), texas (6.0%), and new york (5.2%). most participants identified as white (84.9%), followed by black/african-american (9.1%), asian/asian-american (6.3%), latinx (3.8%), and native american (1.4%). with regard to other participant demographic characteristics at the time 1 assessment, 11% of participants had completed high school or received a ged, 38.2% had attended some college or technical school, 41.5% had graduated from college, and 9.3% had advanced graduate/professional degrees. most participants were employed full-time (68.1%), followed by employed part-time (16.5%) and unemployed (15.3%). annual household income varied, with 31.3% of participants reporting an income of < $35,000, 31.6% reporting an income of $35,000 to $64,999, and 37.1% reporting an income of > $65,000. finally, 19% of participants reported having a current medical condition (e.g., diabetes, hypertension, asthma) that would increase risk of complications from a covid-19 infection and 20.9% reported living alone. across both assessments, few participants j o u r n a l p r e -p r o o f health anxiety during covid-19 10 reported having sought out testing for covid-19 (3%) or having a confirmed covid-19 infection (0.3%). a demographic form was completed by all participants at the time 1 and time 2 assessments. information collected from the demographic form included age, sex, gender, racial/ethnic background, income level, highest level of education attained, employment status, the number of people in the household, state of residence, current medical conditions that could increase risk for susceptibility to and/or complications from covid-19, whether participants had sought out testing for covid-19, and whether participants had been infected with covid-19. covid-19 affective risk was assessed at time 1 using a 3-item self-report measure specifically created for this study. participants responded to questions about covid-19-related worry about risk (i.e., "how worried are you about your level of risk…") in three domains: (a) contracting covid-19, (b) dying from covid-19, and (c) spreading covid-19 to others (should they have it). participants responded to each item using a 5-point likert-type scale ranging from 1 (not at all worried) to 5 (extremely worried). research using similar self-report items (e.g., klein, 2002; rose, 2010) has shown that affective risk assessments are highly correlated with behavioral intentions and health behaviors. given that few participants in this sample reported having a confirmed covid-19 infection, as well as our interest in evaluating personal affective risk assessments (vs. assessments of others' risks), only the items pertaining to contracting and dying from covid-19 were used. these items were summed to create a covid-19 affective risk index. internal consistency was acceptable in this sample (α = .87). the intolerance of uncertainty scale-short form (ius-12; carleton, norton, & asmundson, 2007) was used to assess intolerance of uncertainty at the time 1 assessment. the ius-12 is a 12-item measure that assesses prospective and inhibitory anxiety. this scale was adapted from the 27-item intolerance of uncertainty scale (freeston et al., 1994) that was originally designed to measure six elements related to the inability to withstand uncertainty (i.e., emotional and behavioral consequences of being uncertain, beliefs that uncertainty reflects one's character, expectations that the future is predictable, frustration when the future is not predictable, efforts aimed at controlling the future, and inflexible responses during uncertain situations). example items include, "a small unforeseen event can spoil everything, even with the best of planning," and "i can't stand being taken by surprise." participants rate the extent to which they agree with each item on a 5-point likert-type scale (1 = "not at all characteristic of me;" 2 = "a little characteristic of me;" 3 = "somewhat characteristic of me;" 4 = "very characteristic of me;" 5 = "entirely characteristic of me"). for the present study, responses to each item were summed to create an overall index of intolerance of uncertainty, with possible scores ranging from 12-60 and higher scores reflecting greater intolerance of uncertainty. although carleton et al. (2007) found that the ius-12 has a stable two-factor structure, recent studies have demonstrated that the majority of the measure's variance is accounted for by a single latent variable; consequently, it is recommended that a single, overall ius-12 score is used (hale et al., 2016; lauriola, mosca, & carleton, 2016; shihata, mcevoy, & mullan, 2018) . there is evidence for the reliability and construct validity of the ius-12 within non-clinical and community samples (carleton et al., 2007; carleton, collimore, & asmundson, 2010; lauriola et al., 2016) . internal consistency for this measure in this sample was acceptable (α = .95). the short health anxiety inventory (shai; salkovskis, rimes, warwick, & clark, 2002) is an 18-item measure that was used to assess different dimensions of health anxiety at the time 1 and time 2 assessments. the shai was modified to assess health j o u r n a l p r e -p r o o f health anxiety during covid-19 12 anxiety symptoms over the past week (vs. the past 6-months on the original measure). found that the shai assesses three dimensions of health anxiety: (a) illness likelihood (i.e., the perceived likelihood that a serious illness will be acquired, as well as intrusive thoughts about one's health; 10 items); (b) body vigilance (i.e., attention to bodily sensations or changes in bodily sensations; 3 items); and (c) illness severity (i.e., anticipated burden, impairment, or negative consequences associated with having a serious illness; 4 items). depression and anxiety symptom severity at time 1 were assessed using the 21-item version of the depression anxiety stress scales (dass-21; lovibond & lovibond, 1995) . the current study utilized the depression and anxiety symptom severity subscales as covariates. the dass-21 is a self-report measure that assesses the unique symptoms of depression, anxiety, and stress. participants rate the items on a 4-point likert-type scale indicating how much each 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"). this measure has demonstrated good reliability and validity (antony, bieling, cox, enns, & j o u r n a l p r e -p r o o f health anxiety during covid-19 13 swinson, 1998; roemer, 2001) . internal consistency of the depression (α = .93) and anxiety (α = .89) symptom severity subscales in this sample were acceptable. all procedures received prior approval from the university of toledo's institutional review board. to ensure that the study was not being completed by a bot (i.e., an automated computer program used to complete simple tasks), participants responded to a completely automatic public turing test to tell computers and humans apart (captcha) at the time 1 assessment prior to providing informed consent. participants were also informed on the consent form 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." initial 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 multiple-choice 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 of the time 1 assessment). workers who completed the initial assessment and whose data were considered valid (based on attention check items and geolocations; n = 500) were compensated $3.00 for their participation and invited to participate in the one-month follow-up assessment. health anxiety during covid-19 14 one-month following completion of the time 1 assessment, participants were contacted via cloudresearch (litman et al., 2017) to complete the time 2 assessment. this online platform allows researchers to email participants a link to follow-up assessments while maintaining anonymity (i.e., study personnel never see email addresses) by using their amazon worker id numbers (provided by mturk). of the 500 participants who completed the initial assessment, 77% (n = 386) completed the follow-up assessment. there were no significant differences in time 1 intolerance of uncertainty or health anxiety dimensions between participants who completed (vs. did not complete) the follow-up assessment (ps > .11); however, participants procedures for assessing the validity of the time 2 data (i.e., examining attention check items and geolocations) were similar to those used for the time 1 assessment. participants who failed two or more attention check items at the time 2 assessment were removed from the study (n = 3); the remainder were compensated $3.00 for their participation. in addition, two participants were excluded for non-reconcilable differences in demographic data between the time 1 and time 2 assessments, and 17 additional participants were excluded for incomplete data on the primary variables of interest, resulting in a final sample size of 364. results of the hierarchical linear regression analyses examining the main and interactive effects of time 1 covid-19 affective risk and intolerance of uncertainty on time 2 health anxiety dimensions are presented in table 2 . the overall model was significant, accounting for 61% of the variance in the time 2 illness likelihood dimension of health anxiety, f (4, 359) = 141.14, p < .001, f = 1.24. the addition of time 1 covid-19 affective risk and intolerance of uncertainty in the second step of the model accounted for additional significant variance in time 2 illness likelihood above and beyond time 1 illness likelihood, δr 2 = .02, f (2, 360) = 11.04, p < .001, f = .24, with both variables demonstrating a significant unique positive association with time 2 illness likelihood. the addition of the interaction term did not significantly improve the model, δr 2 = .001, f (1, 359) = 1.38, p = .242, f = .03. the addition of the interaction term did not significantly improve the model, δr 2 = .00, f (1, 359) = .15, p = .697, f = .00. the overall model was significant, accounting for 55% of the variance in the time 2 to ensure that the significant interaction could not be attributed to other demographic or psychiatric variables, the regression analysis was rerun with the following covariates included in this study sought to examine the unique and interactive prospective relations of covid-19 affective risk assessments (i.e., worry about risk for contracting or dying from and intolerance of uncertainty to health anxiety one month later. hypotheses were partially supported. first, as predicted, covid-19 affective risk assessments and intolerance of uncertainty at time 1 were uniquely associated with later perceived likelihood that a serious illness would be acquired (i.e., illness likelihood subscale on the shai) and anticipated negative consequences of having a serious illness (i.e., illness severity subscale on the shai). these findings are consistent with past research demonstrating relationships between health anxiety and both intolerance of uncertainty (e.g., and concerns regarding perceived vulnerability to disease (e.g., duncan, schaller, & park, 2009 ). however, only intolerance of uncertainty at time 1 was found to be uniquely associated with time 2 body vigilance. the items assessing body vigilance on the shai focus on bodily sensations in general or aches and pains. although worry and anxiety regarding risk for contracting or dying from covid-19 j o u r n a l p r e -p r o o f health anxiety during covid-19 19 would be expected to amplify sensitivity to bodily sensations (consistent with a seek to avoid process; barlow, 2002) , it is possible that this process might be more evident for bodily sensations that are specifically associated with covid-19 infection (e.g., fever, shortness of breath, headache). however, as an individual difference factor that is not unique to covid-19, intolerance of uncertainty may be more likely to increase awareness of bodily sensations in general to identify any potential sources of health threat, thus increasing a sense of certainty, control, or predictability. contrary to hypotheses, intolerance of uncertainty was not found to moderate the association between time 1 covid-19 affective risk assessments and time 2 illness likelihood or body vigilance. in addition, although intolerance of uncertainty was found to moderate the association between covid-19 affective risk assessments and time 2 illness severity, the nature of this interaction was different than what was predicted. specifically, time 1 covid-19 affective risk assessments were significantly positively associated with time 2 illness severity only at mean and low levels of intolerance of uncertainty. at high levels of intolerance of uncertainty, no significant association was found between covid-19 affective risk assessments and health anxiety. this finding highlights the multiple ways in which individuals may develop anxiety surrounding the potential negative consequences associated with illness. even in the absence of an established vulnerability for the development of health anxiety (i.e., intolerance of uncertainty), elevated worry about risk for contracting or dying from covid-19 appears to be sufficient for the greater anticipation of negative consequences associated with having an illness. the experience of frequent worry thoughts surrounding risk for covid-19 infection or mortality may increase health anxiety by contributing to the increased generation of potential catastrophic outcomes that could occur if one were infected with the virus. indeed, in other health conditions j o u r n a l p r e -p r o o f (e.g., irritable bowel syndrome), worry has been found to contribute to increased suffering through catastrophizing (lackner & quigley, 2005) . however, among individuals high in intolerance of uncertainty, covid-19 affective risk assessments seem less relevant to later health anxiety, providing further evidence that intolerance of uncertainty may be a strong risk factor for the development or exacerbation of health anxiety. such a finding is consistent with previous research showing that intolerance of uncertainty predicts health anxiety above and beyond other established anxiety risk factors (e.g., anxiety sensitivity, negative affect; fergus & bardeen, 2013) . study limitations warrant consideration. first, all outcomes were assessed using selfreport questionnaires, which have the potential to be influenced by social desirability biases or recall difficulties. in addition, we used an unpublished, two-item measure developed specifically for the purposes of this study to assess covid-19 affective risk assessments. although this measure demonstrated associations with our other variables in the expected direction, it is possible that our measure did not provide a comprehensive evaluation of covid-19 affective risk assessments. at the time this study began, other validated measures of covid-19 affective risk assessments were not available. however, since that time, several measures have been published that may provide a better assessment of covid-19 affective risk assessments or the stress and anxiety associated with covid-19 more generally, such as the covid stress scales (taylor et al., 2020) and the coronavirus anxiety scale . in addition, our measures of intolerance of uncertainty and health anxiety were not specific to covid-19; thus, findings cannot speak to the extent to which intolerance of uncertainty surrounding the covid-19 pandemic in particular influences anxiety surrounding the experience and consequences of covid-19 related bodily sensations. in addition, given our recruitment methods and sample j o u r n a l p r e -p r o o f health anxiety during covid-19 21 (i.e., self-selected mturk workers), results may also not generalize to the larger u.s. population, adults in other countries, or particularly vulnerable populations (e.g., individuals with chronic medical conditions; health care workers; hospitalized patients). replication of our findings is needed within other samples. in addition, although covid-19 affective risk assessments and intolerance of uncertainty were found to predict later health anxiety, it is important to note that average health anxiety levels at time 2 were not at clinical levels (mean shai scores among individuals with hypochondriasis = 32.58; alberts et al., 2013) . moreover, it is not clear if the levels of health anxiety observed in this study are associated with engagement in adaptive or maladaptive health behaviors. health anxiety is conceptualized as a dimensional variable (taylor & asmundson, 2004) , and moderate levels of health anxiety may be functional in the context of a pandemic, increasing motivation to engage in protective behaviors such as social distancing, hand washing, and wearing a mask when outside of the home. studies employing multiple follow-up assessments are needed to determine whether the health anxiety stemming from covid-19 affective risk assessments and intolerance of uncertainty predicts later engagement in adaptive or maladaptive health behaviors. likewise, research is needed to examine the impact of the covid-19 pandemic on health anxiety within more vulnerable populations, such as individuals with pre-existing illness anxiety disorder or generalized anxiety disorder. despite limitations, findings lend support to the hypothesis that the covid-19 pandemic will result in elevated health anxiety (asmundson & taylor, 2020b) , and add to the growing body of literature on the mental health consequences of this pandemic (cao et al., 2020; gonzález-sanguino et al., 2020; harper et al., 2020; huang & zhao, 2020; jungmann & witthöft, 2020; lee et al., 2020; mckay et al., 2020; moghanibashi-mansourieh, 2020; zhang et al., 2020). specifically, our findings demonstrate that covid-19 affective risk assessments and intolerance of uncertainty are uniquely associated with various dimensions of health anxiety one month later. moreover, in addition to providing further evidence that high levels of intolerance of uncertainty may increase risk for later health anxiety, results highlight one pathway (i.e., affective-based risk assessments) through which individuals without high levels of intolerance of uncertainty may still be susceptible to later health anxiety during this time. specifically, the extent to which individuals feel that they are at risk for covid-19 infection and death was associated with elevated health anxiety one-month later among individuals with mean and low levels of intolerance of uncertainty. as such, findings highlight a number of potential targets for preventing the development of severe health anxiety that could lead to maladaptive behaviors during the current pandemic. for example, acceptance-and mindfulness-based behavioral interventions (e.g., acceptance-based behavioral therapy for generalized anxiety disorder; roemer, orsillo, & salters-pedneault, 2008 ) may be particularly useful for addressing worry about risk for contracting or dying from covid-19. psychoeducation on effective behaviors for mitigating risk for covid-19 infection may also reduce worry, and ultimately health anxiety, by modifying risk assessments and increasing a sense of control. cognitive-behavioral interventions that specifically target intolerance of uncertainty (e.g., hebert & dugas, 2019; ladouceur et al., 2000) may also have utility in reducing risk for future health anxiety during this particularly stressful and indeed uncertain time. j o u r n a l p r e -p r o o f the short health anxiety inventory: psychometric properties and construct validity in a non-clinical sample health anxiety, hypochondriasis, and the anxiety disorders the short health anxiety inventory: a systematic review and meta-analysis psychometric properties of the 42-item and 21-item versions of the depression anxiety stress scales in clinical groups and a community sample health anxiety: current perspectives and future directions coronaphobia: fear and the 2019-ncov outbreak how health anxiety influences responses to viral outbreaks like covid-19: what all decision-makers, health authorities, and health care professionals need to know anxiety and its disorders intolerance of uncertainty and social anxiety investigating the construct validity of intolerance of uncertainty and its unique relationship with worry amazon's mechanical turk: a new source of inexpensive, yet high-quality, data? comparing the roles of ambiguity and unpredictability in intolerance of uncertainty the psychological impact of the covid-19 epidemic on college students in china it's not just the judgements-it's that i don't know": intolerance of uncertainty as a predictor of social anxiety increasingly certain about uncertainty: intolerance of uncertainty across anxiety and depression fearing the unknown: a short version of the intolerance of uncertainty scale separate but equal? a comparison of participants and data gathered via amazon's mturk, social media, and face-to-face behavioral testing coronavirus (covid-19) online panels in social science research: expanding sampling methods beyond mechanical turk intolerance of uncertainty and problem orientation in worry perceived vulnerability to disease: development and validation of a 15-item self-report instrument cyberchondria and intolerance of uncertainty: examining when individuals experience health anxiety in response to internet searches for medical information anxiety sensitivity and intolerance of uncertainty: evidence of incremental specificity in relation to health anxiety intolerance of uncertainty moderates the relationship between catastrophic health appraisals and health anxiety the consequences of covid-19 pandemic on mental health and implications for clinical practice why do people worry a meta-analysis of the relation of intolerance of uncertainty to symptoms of generalized anxiety disorder, major depressive disorder, and obsessive-compulsive disorder mental health problems and social media exposure during the covid-19 outbreak cognitive and behavioral responses to illness information: the role of health anxiety resolving uncertainty about the intolerance of uncertainty scale-12: application of modern psychometric strategies functional fear predicts public health compliance in the covid-19 pandemic attentive turkers: mturk participants perform better on online attention checks than do subject pool participants introduction to mediation, moderation, and conditional process analysis: a regression-based approach behavioral experiments for intolerance of uncertainty: challenging the unknown in the treatment of generalized anxiety disorder a comparison of intolerance of uncertainty in analogue obsessive-compulsive disorder and generalized anxiety disorder generalized anxiety disorder, depressive symptoms and sleep quality during covid-19 outbreak in china: a web-based cross-sectional survey thinking versus feeling: differentiating between cognitive and affective components of perceived cancer risk the importance of affectively-laden beliefs about health risks: the case of tobacco use and sun protection health anxiety, cyberchondria, and coping in the current covid-19 pandemic: which factors are related to coronavirus anxiety? the shape of and solutions to the mturk quality crisis comparative risk estimates relative to the average peer predict behavioral intentions and concern about absolute risk pain catastrophizing mediates the relationship between worry and pain suffering in patients with irritable bowel syndrome efficacy of a cognitive-behavioral treatment for generalized anxiety disorder: evaluation in a controlled clinical trial hierarchical factor structure of the intolerance of uncertainty scale short form (ius-12) in the italian version clinically significant fear and anxiety of covid-19: a psychometric examination of the coronavirus anxiety scale incubation period and other epidemiological characteristics of 2019 novel coronavirus infections with right truncation: a statistical analysis of publicly available case data turkprime. com: a versatile crowdsourcing data acquisition platform for the behavioral sciences risk as feelings manual for the depression anxiety stress scales are dysfunctional beliefs about illness unique to hypochondriasis? anxiety regarding contracting covid-19 related to interoceptive anxiety sensations: the moderating role of disgust propensity and sensitivity see how all 50 states are reopening see which states and cities have told residents to stay at home attentional bias in generalized anxiety disorder versus depressive disorder attentional bias to threat in clinical anxiety states assessing the anxiety level of iranian general population during covid-19 outbreak suicide mortality and coronavirus disease 2019-a perfect storm practitioner's guide to empirically based measures of anxiety efficacy of an acceptance-based behavior therapy for generalized anxiety disorder: evaluation in a randomized controlled are direct or indirect measures of comparative risk better predictors of concern and behavioural intentions? the health anxiety inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis covid-19 infection: origin, transmission, and characteristics of human coronaviruses a bifactor model of intolerance of uncertainty in undergraduate and clinical samples: do we need to reconsider the twofactor model? psychological assessment the psychology of pandemics: preparing for the next global outbreak of infectious disease treating health anxiety: a cognitive-behavioral approach development and initial validation of the covid stress scales mental health and psychosocial considerations during the covid-19 outbreak rolling updates on coronavirus disease (covid-19) use of hydroxychloroquine and chloroquine during the covid-19 pandemic: what every clinician should know the differential psychological distress of populations affected by the covid-19 pandemic 17 * .45 ** .28 ** .23 ** .41 ** .22 ** .26 ** 2. t1 ius 27 ** .46 ** .41 ** .28 ** .53 ** t1 illness likelihood t1 body vigilance t1 illness severity t2 illness likelihood t2 body vigilance t2 illness likelihood affective risk = covid-19 affective risk assessments ius = intolerance of uncertainty scale; illness likelihood = short health anxiety inventory illness likelihood subscale; body vigilance = short health anxiety inventory body vigilance subscale; illness severity = short health anxiety inventory illness severity subscale key: cord-034687-57n88v6t authors: maldonado, rafael; cabañero, david; martín-garcía, elena title: the endocannabinoid system in modulating fear, anxiety, and stress date: 2020-09-17 journal: dialogues clin neurosci doi: 10.31887/dcns.2020.22.3/rmaldonado sha: doc_id: 34687 cord_uid: 57n88v6t the endocannabinoid system is widely expressed in the limbic system, prefrontal cortical areas, and brain structures regulating neuroendocrine stress responses, which explains the key role of this system in the control of emotions. in this review, we update recent advances on the function of the endocannabinoid system in determining the value of fear-evoking stimuli and promoting appropriate behavioral responses for stress resilience. we also review the alterations in the activity of the endocannabinoid system during fear, stress, and anxiety, and the pathophysiological role of each component of this system in the control of these protective emotional responses that also trigger pathological emotional disorders. in spite of all the evidence, we have not yet taken advantage of the therapeutic implications of this important role of the endocannabinoid system, and possible future strategies to improve the treatment of these emotional disorders are discussed. anxiety disorders are the most frequent mental alterations worldwide in different socioeconomic regions and are linked with significant comorbidities. 1 fear and worry are core symptoms of the entire spectrum of anxiety disorders in the diagnostic and statistical manual of mental disorders, 5 th edition (dsm-5). 2 these disorders have a complex and multifactorial origin resulting from the interaction of multiple genes and environmental factors that lead to large interindividual variability. chronic stress is one of the main environmental risk factors that disrupt coping circuits and contributes to the etiopathology of these psychiatric disorders. in contrast, exposure to mild stress may act as a protective factor by improving coping strategies in future stressful events. 3 the reasons why some individuals exposed to similar chronic stress are vulnerable and develop anxiety disorders whereas others are resilient remain unknown. importantly, there is a lack of successful treatments for these disorders, revealing an urgent need for a better understanding of their neurobiological mechanisms. remarkable progress has recently been made in understanding the circuitries underlying anxiety disorders. 3 a large amount of this neurobiological research has been focused on networks targeting the limbic and the hypothalamic-pituitary-adrenal (hpa) axis and its modulation by different neurotransmitters, with special emphasis on the endocannabinoid system. the endocannabinoid system is extensively distributed in the central nervous system (cns) and plays a crucial role in the control of emotional responses. 4 thus, cannabis users identify a subjective sensation of relaxation after consumption, which has been linked here, we discuss recent advances in the role of the endocannabinoid system in determining the value of fearevoking stimuli and promoting appropriate behavioral responses for stress resilience. we review the alterations in endocannabinoid activity during fear-, stress-, and anxiety-related dysfunctions. fear and anxiety neurobiological substrates mostly overlap and interact with the neurocircuitry that governs the stress response. the concept of stress used in this review will be specific to the stress reaction and will not involve heterogeneous concepts such as subjective distress. 6 this stress is directly related to the activation of the limbic-hpa axis and stress hormones such as corticotropin-releasing hormone (crh), adrenocorticotropic hormone (acth), and glucocorticoids, a circuit also highly relevant for fear and anxiety. links among the limbic system, fear circuits, and treatments for worry and fear across the spectrum of anxiety disorders are discussed throughout this review. understanding the neurobiological mechanisms underlying resilience versus vulnerability to develop anxiety disorders is expected to open novel therapeutic interventions to battle these disorders. fear is the emotional response to real or perceived imminent threats, whereas anxiety is the anticipation of future threat. fear is a normal emotion when it appears under a context of the threat, and it is considered an important part of the evolutionary reaction of survival that prepares figure 1 . overview of the endocannabinoid-mediated synaptic signaling at glutamatergic terminals. the endocannabinoid system is a retrograde neuromodulator. after neuronal depolarization at the postsynaptic level, the endocannabinoids are synthesized on demand and travel backwards to bind the presynaptic cannabinoid 1 receptor (cb 1 r). through this synaptic mechanism, the endocannabinoid system controls different pathophysiological processes including fear, stress, and anxiety. in detail, glutamate released from presynaptic terminals stimulates both ionotropic and metabotropic glutamate receptors, such as n-methyl-d-aspartate (nmda) and metabotropic glutamate receptor 1 and 5 (mglur1/5) receptors, leading to postsynaptic depolarization through ca 2+ entry and gq-protein activation. increased intracellular ca 2+ concentration stimulates endocannabinoid synthesis through phospholipase c (2-arachidonoylglycerol, 2-ag) and phospholipase d (anandamide, aea). 2-ag synthesis is also mediated by gq-protein activation. endocannabinoids are released to the synaptic cleft and activate presynaptic cb 1 r. cb 1 r activation by the endocannabinoids aea and 2-ag triggers several intracellular pathways via gi/o proteins, including inhibition of adenylate cyclase (ac) activity, membrane hyperpolarization through activation of k + channel currents and blockage of ca 2+ voltage-dependent channels, which results in the inhibition of glutamate release. abbreviations: 2-ag, 2-arachidonoylglycerol; ac, adenylate cyclase; aea, anandamide; cb 1 , cannabinoid 1 receptor; dag, diacylglycerol; daglα, diacyl glycerol lipase α; mglur1/5; metabotropic glutamate receptor 1 and 5; nape, n-arachidonoyl-phosphatidyl ethanol amine; nmda, n-methyl-d-aspartate; plc, phospholipase c; pld, phospholipase d; pip2, phosphatidyl inositol bisphosphate to fight or escape. appropriate fear responses are adaptive and allow the individual to cope with dangerous or stressful situations, but exaggerated fear responses can lead to anxiety disorders. 2 although fear and anxiety can overlap, they also differ. thus, fear is often associated with surges of autonomic arousal necessary for a fight, thoughts of immediate danger, and escape behaviors, whereas anxiety is more often associated with muscle tension and caution in preparation for future danger and with alert or avoidance behaviors. 7 the amygdala is a limbic hub of communications crucial for fear behavior owing to its anatomical connections integrating sensory and cognitive information ( figure 2) . the emotion of fear may be controlled through reciprocal networks with key areas of prefrontal cortex (pfc). motor responses of fear, mainly fighting and escape, are regulated by connections between the amygdala and periaqueductal gray. endocrine responses that complement fear are mainly mediated by connections between amygdala and hypothalamus, leading to changes in the hpa axis. 7 the autonomic nervous system is also stimulated in response to fearful stimuli, activating the cardiovascular system (enhanced blood pressure and heart rate) through increased connectivity between amygdala and locus ceruleus, the major source of brain noradrenergic innervation. 8 fear and anxiety disorders can also be elicited internally from traumatic memories stored in the hippocampus and reactivated by the amygdala. in posttraumatic stress disorder (ptsd), persistent, recurring memories of traumatic events occur, which the individual is unable to extinguish. 3 extinction plays a crucial role and is considered an active associative-learning process. 9 in normal conditions, natural stimuli that signal threat provoke an innate fear response. this response is used in the fear conditioning paradigm to study fear-based disorders based on pavlovian conditioning. such an associative learning process consists of pairing a neutral conditioned stimulus (cs) with an aversive unconditioned stimulus (us) that produces a conditioned fear response (freezing in rodents, skin conductance response in humans). in ptsd patients, fear learning, specifically extinction, is thought to be impaired. animal models of pathological fear learning are essential to find effective treatments for such disorders. in this context, the endocannabinoid system plays figure: an overview of this interconnected circuit is represented in the human brain. the amygdala has bilateral glutamatergic interconnections with the prefrontal cortex and the hippocampus to associate emotional, cognitive, and executive functions. the amygdala controls the activity of midbrain, brainstem nuclei, and neuroendocrine areas (hypothalamus and pituitary anterior) through gabaergic projections that mediate emotional, motor, and neuroendocrine responses to fear, stress, and anxiety. right figure: precise modulation of fear expression by cannabinoid signaling in the same circuit targeting the amygdala is represented in the rodent brain at the bottom right panel. in detail, the role of the cannabinoid 1 receptor (cb 1 r) depends on the specific cell type and brain region where they are expressed. on gabaergic neurons, activation of cb 1 r leads to a decrease in active coping strategies in the fear conditioning paradigm, which may facilitate anxiogenic-like responses, possibly due to a decreased activity of gabaergic interneurons in the basolateral amygdala that produces an activation of glutamatergic neurons projecting to the central amygdala, which results in enhanced activity of the central amygdala. conversely, the activation of cb1r on glutamatergic terminals in the central amygdala induces a decrease in passive coping strategies in the fear conditioning paradigm facilitating anxiolytic-like responses, possibly due to attenuated glutamatergic excitation from the basolateral amygdala, which results in a decreased activation of gabaergic neurons in the central amygdala that project to the midbrain and other brainstem nuclei. these results point to a supposed bimodal control of fear expression by cannabinoid signaling in amygdala-dependent circuits that can also be modulated by glutamatergic inputs from the prefrontal cortex and the hippocampus. abbreviations: bla, basolateral amígdala; cb 1 r, cannabinoid 1 receptor; cea, central amygdala; pfc, prefrontal cortex the endocannabinoid system in fear, anxiety, and stress -maldonado et al a crucial role in fear-related brain circuits and is crucially involved in the modulation of fear-memory processing. 8 the role of the endocannabinoid system in modulating the neurobiological mechanisms involved in fear behavior has been widely investigated. 9 two neuronal populations expressing cb 1 r widely distributed thorough the brain have been described: cortical glutamatergic and gabaergic forebrain neurons. the equilibrium between gabaergic and glutamatergic transmission provides an appropriate emotional reactivity in physiological conditions ( figure 2 ). under stressful circumstances, the glutamatergic tone increases, producing an imbalance between excitatory and inhibitory transmission. to compensate for this glutamatergic overexcitation, an adaptive compensatory mechanism is activated by cb 1 r downregulation in gabaergic terminals. this downregulation promotes increased gabaergic inhibition of glutamatergic transmission that reestablishes the equilibrium between excitation and inhibition. 8 the behavior of mutant mice lacking cb 1 r in cortical glutamatergic neurons indicates that the modulatory effect of cb 1 r in these excitatory neurons plays a complementary role in fear extinction. 10 therefore, the role of cb 1 r depends on the specific cell type and brain region where they are expressed. importantly, the deletion of cb 1 r in forebrain gabaergic neurons of gaba-cb 1 r knockouts leads to an augmentation of active coping strategies in the fear conditioning paradigm, possibly due to an increased inhibition of glutamatergic cells in the basolateral amygdala (bla), which reduces central amygdala (cea) excitation. 11 conversely, the deletion of cb 1 r in cortical glutamatergic neurons of glu-cb 1 r knockouts induces augmentation of passive coping strategies in the fear conditioning paradigm, possibly due to increased glutamatergic excitation in the bla, which results in cea hyperactivation. 11 these results point to a bimodal cannabinoid control of fear in amygdala-dependent circuits 12 (figure 2 ). in agreement, low tetrahydrocannabinol (thc) doses have been proposed to act preferentially at cb 1 r on glutamatergic neurons, whereas high thc doses have been proposed to act also at gabaergic neurons. 13 cb 1 r is less abundant on cortical glutamatergic neurons, but its activation produces more pronounced effects than on gabaergic neurons. 14 furthermore, cb 1 r antagonists microinjected in the bla impair long-term extinction, and cb 1 r antagonism into the cea reduces within-session extinction. 15 the infralimbic pfc also has an important role in fear extinction, as shown by the impaired fear extinction after cb 1 r blockade in this subregion. 16 in agreement with these data, mice deficient in diacylglycerol lipase-α (daglα), the enzyme involved in 2-ag synthesis, have reduced 2-ag brain levels and display a phenotype related to impaired fear extinction. 17 in contrast, pharmacological inhibition of monoacylglycerol lipase (magl), the enzyme involved in 2-ag degradation, enhances 2-ag levels and impairs fear extinction via cb 1 r of gabaergic neurons. 17 these results suggest that an optimal level of 2-ag is needed for appropriate processing of fear responses and that altered 2-ag levels impair the extinction process. 5 with respect to anandamide, inhibition of the enzyme involved in its degradation, fatty acid amide hydrolase (faah) in the bla, facilitates fear extinction by cb 1 r activation. 18 re-exposure to the cs alone increases the activity of the endocannabinoid system to promote extinction, and the fear response is reduced after cb 1 r activation. 5 therefore, the endocannabinoid system is crucial for appropriate fear extinction. on the other hand, chronic stress can have deleterious effects regarding the extinction of conditioned fear, which may interfere in the treatment of ptsd patients. it is hypothesized that chronic stress creates a hypocannabinergic state resulting in impaired fear extinction that can be alleviated by cb 1 r agonists. 5 chronic stress can produce a switch from passive to active coping strategies, and constitutive cb 1 r deletion disrupts this adaptation favoring passive responses that seem to depend on cb 1 r expressed on cortical glutamatergic neurons. 11 conversely, cb 1 r expressed on forebrain gabaergic neurons are related to coping strategies because mice lacking cb 1 r in these neurons display predominantly active behaviors. 11 importantly, when the responses to cs are measured during a long-term period of cs presentation, no differences in the quantity of fear responses are observed one of the main medical reasons for cannabis consumption is anxiety relief, although anxiogenic responses are also frequently reported after cannabinoid consumption in these conditional mutant mice, suggesting that cb 1 r in cortical glutamatergic or forebrain gabaergic neurons does not affect the memory of the conditioning event, but determines the coping style of an individual toward the threat. 5 stress is an alteration of homeostasis as a consequence of external or internal threats. indeed, acute stressors elicit immediate and protracted neuroendocrine responses with protective effects. these responses involve the activation of the sympathetic nervous system and the hpa axis. within seconds of stress exposure, noradrenaline and adrenaline are released through sympathetic postganglionic neurons and adrenal gland chromaffin cells contributing to fight-orescape protective responses. in parallel, the hpa axis is activated through crh release from the hypothalamus, which leads to acth release from the pituitary gland. acth in the general blood stream reaches adrenal glands that pour glucocorticoids into the blood circulatory system. these corticoids activate glucocorticoid receptors that increase glucose availability and trigger transcriptional changes partly directed to limit inflammation and repair processes that can be postponed. the endocannabinoid system present in the hpa axis and the sympathetic nervous system plays a crucial role in regulating stress responses ( figure 3) . early studies showed that repeated thc modified dopamine b-hydroxylase activity in rodent serum, a measure of sympathetic system activation. 19 this effect was different depending on the basal status of exposed subjects revealing a complex modulatory role of the endocannabinoid system: thc alleviated sympathetic activation in naive mice but potentiated this response in rodents subjected to immobilization stress. cb 1 r controls peripheral and central adrenaline, and noradrenaline release involved in stress-induced memory impairment, 20 and the sympathetic nervous system partly mediates the anxiety-like effects observed after cb 1 r blockade. 21 in regard to the hpa axis, pharmacological and knockout studies demonstrate that cb 1 r activity limits hypothalamic crh release. 22 cb 1 r is also present in the pituitary gland and adrenal cortex cells, where it restricts acth and glucocorticoid release, respectively. 22 on the contrary, glucocorticoids induce fast increases in endocannabinoid synthesis in brain areas that shape the perception of psychological stressors. 23 these regions include areas involved in cognitive processes such as pfc and hippocampus, and areas related with affective responses such as the amygdala. 24 glucocorticoids released after acute stressors activate g-protein membrane receptors in the bla, promoting a rapid increase in retrograde 2-ag signaling that leads to suppression of gabaergic synaptic inputs onto bla principal neurons, inducing fast increases in anxiety-like behavior. 25 these limbic areas are further connected with the hypothalamus to modulate under stress conditions, the hpa axis is activated to produce an adaptive defensive response to stress. to counteract excessive hpa-axis activation, cb 1 r activity limits the release of hypothalamic corticotropin-releasing hormone. cb 1 r is also present in the pituitary gland and adrenal cortex cells, where they restrict adrenocorticotropin hormone and glucocorticoid release, respectively. on the contrary, glucocorticoids induce fast increases in endocannabinoid synthesis in brain areas that shape the perception of stress. these regions include the prefrontal cortex, the hippocampus, and the amygdala. indeed, glucocorticoids released after acute stressors promote a rapid increase in retrograde 2-arachidonoylglycerol (2-ag) signaling in these brain areas leading to decreased gabaergic release in the amygdala that induces a fast increase in anxiety-like behavior. original article the endocannabinoid system in fear, anxiety, and stress -maldonado et al stress responses (figure 3) . cb 1 r located in these structures represent a unique opportunity for pharmacological modulation. however, the use of exogenous cb 1 r ligands has been associated with serious health problems, from thc effects promoting addictive behaviors 26 and anxiety disorders 27 to the psychiatric alterations (anxiety, depression, or suicidal behaviors) related to the cb 1 r inverse agonist rimonabant. 28 therefore, a great deal of research has focused on the pharmacological modulation of endogenous cannabinoids as an alternative approach for the treatment of stress-induced alterations. in this context, the enzymes involved in the synthesis and degradation of endocannabinoids represent potential effective targets with possible better safety profiles than drugs directly acting on cb 1 r. models of acute immobilization stress provoke immediate increases in faah activity, the enzyme involved in anandamide degradation, in amygdala and hippocampus. enhancing the activity of this degrading enzyme results in glucocorticoid release and stress-related anxiety-like behavior, 29 whereas faah inhibition or costimulation of cb 1 r and trpv 1 (transient receptor potential cation channel subfamily v member 1) receptors decreases stress-induced corticoid release and anxiogenic behavior. 30, 31 restraint stress or corticosterone treatments also produce a delayed increase in 2-ag levels in the hypothalamus, pfc, and hippocampus, associated with a decreased hpa-axis activity 32 that modulates memory processes and pain perception after stressful stimuli. 33 therefore, acute stress exposure has emotional and physiological consequences related with decreased anandamide production, but also favors increased 2-ag levels that limit the stress response and have an impact on cognitive performance. 33 in contrast to acute stress, chronic stress predisposes for the development and aggravation of psychiatric disorders, including anxiety, depression, ptsd, and drug addiction. 34 chronic stress induces prominent and sustained changes in the endocannabinoid system, leading to decreases in cb 1 r signaling in brain regions related with emotional processing such as the hippocampus, nucleus accumbens, pfc, dorsal raphe nucleus, hypothalamus, and amygdala. 5 indeed, sustained corticosterone increments after repeated restraint stress promote faah activity through glucocorticoid stimulation. 29 as a consequence, anandamide levels are maintained low in the hippocampus, hypothalamus, pfc, and amygdala, 35 which leads to hyperexcitability and struc-tural remodeling of amygdalar circuits involved in anxiety. indeed, a rat model of pathological anxiety reveals constitutive increases in corticotropin-releasing factor (crf) signaling that lead to sustained elevation of faah activity and dysregulation of inhibitory control of cea glutamatergic synapses. 36 inhibition of faah hyperactivity prevents these effects of chronic stress 37 and protracted structural and functional changes that chronic stress promotes in bla glutamatergic neurons. 38, 39 interestingly, divergent results have been obtained after exposure to other models of chronic stress, 40 suggesting that the nature of the stress or the existence of previous experiences can lead to differentiated stress-induced neuroadaptations. indeed, repeated exposure to the same stress provokes increased 2-ag concentrations that underlie habituation to stress in adults. 41 further increasing 2-ag levels through blockade of 2-ag degradation prevents the decrease in hippocampal neurogenesis and long-term synaptic effects associated with chronic stress. 42 deletion of the 2-ag synthesizing enzyme daglα in pfc strengthens glutamatergic activity in a bla-pfc-bla circuit that facilitates stress-induced anxiety-like behavior. 43 these data show that facilitating synthesis or inhibiting degradation of anandamide and 2-ag have overlapping consequences, suggesting the therapeutic potential of these enzyme modulators for the treatment of stress-related disorders. the redundancy exhibited by 2-ag and anandamide could potentially be exploited to design drug combinations with lower doses of active ingredients and may be useful to tackle different aspects of chronic stress disorders at once. contemporary society is exposed to a multiplicity of external factors that constitute sources of anxiety, including excessive workloads, difficult personal relationships, sexual abuse, drug consumption, digital social media, or even current infectious disease pandemics. 44 anxiety can be defined as a mental state of discomfort triggered by uncertain threats. 45 these threats are estimated to be distant in time or space and lead to anticipatory affective, cognitive, behavioral, and physiological changes and a continuous risk assessment that can persist until the uncertainty is resolved. 46 internal changes are adaptive and favor behaviors that protect the organism from dangerous situations, although in certain conditions become disproportional and result in anxiety-related disorders. one of the main medical reasons for cannabis consumption is anxiety relief, 47 although anxiogenic responses are also frequently reported after cannabinoid consumption. 48 indeed, high doses or long-term treatments with thc induce anxiety in humans and rodents. on the other hand, acute administration of the non-psychotropic cannabinoid cannabidiol (cbd) or low thc doses can relieve anxiety-related behavior. 47 the cre-lox technology allowed the dissection of biological substrates underlying this dual effect of cb 1 r activation. glutamatergic and gabaergic neurons expressing cb 1 r are widely distributed in key brain areas involved in anxiety, such as the amygdala, hippocampus, or pfc. presynaptic cb 1 r of cortical glutamatergic neurons inhibit glutamate release, and their activation induces anxiolysis. 49 in agreement, anxiety-like behavior is observed in mice lacking cb 1 r in cortical glutamatergic neurons, 8, 50 and reinstatement of cb 1 r expression in glutamatergic neurons of cb 1 r-knockout mice partly restores normal anxiety levels. 51 in contrast, cb 1 r activation from the larger population of forebrain gabaergic neurons restricts the inhibitory gaba tone and facilitates anxiety-like behavior in basal conditions. 49 this function is abrogated in mice lacking cb 1 r in forebrain gabaergic neurons. 50, 52, 53 interestingly, the presence of cb 1 r in forebrain gabaergic neurons was also essential for the serenity obtained after physical exercising, interpreted as the opposite of anxiety-like behavior. 54 thus, although stimulation of cb 1 r of forebrain gabaergic neurons is related with the anxiogenic effects of high thc doses, the cannabinoid tone of this gabaergic neuronal population can have bidirectional anxiolytic or anxiogenic effects depending on the basal status of the individuals. 54 this complex modulatory function of the endocannabinoid system on anxiety needs to be carefully understood to allow efficient modulation in the clinics. recent advances have started to unravel the complex circuitry involved in the cannabinoid modulation of anxiety. bla represents a critical brain center for the onset of anxiety in response to environmental cues. systemic and intra-amygdalar administration of 2-ag and anandamide reuptake inhibitors demonstrate overlapping effects reducing anxiety through cb 1 r expressed in glutamatergic synapses. [55] [56] [57] at least part of this anxiogenic glutamatergic input to the amygdala comes from pfc and hippocampus. prelimbic pfc glutamatergic neurons are active after threat exposure, as demonstrated by recent optogenetic and cell-specific gene deletion experiments. 43 a traumatic experience (foot-shock) in mice facilitates 2-ag depletion and subsequent enhancement of glutamatergic neurotransmission in this bla-pfc-bla pathway to trigger anxiety-like behavior. 43 the relevance of this circuitry is reflected in clinical studies showing that the anxiolytic effects of thc are associated with reduced activity and disrupted connectivity between these two brain areas. 58 a persistent weakening of the endocannabinoid tone could lead to enhanced functional bla-pfc coupling and progression from a physiological stress to an anxiety disorder. the bla also receives glutamatergic projections from the hippocampus, and these projections are bidirectionally controlled by endocannabinoids. in a similar way, increases in hippocampal 2-ag or anandamide promote stress resilience and anxiolysis, whereas cb 1 r blockade or inhibition of 2-ag production precipitates anxiety. 59 local cb 1 r activity has also been associated with anxiogenesis in certain circuits. thus, the amygdala sends cb 1 r -positive projections to the bed nucleus of the stria terminalis (bnst), a brain region closely involved in anxiety. this area is connected with midbrain structures, including the ventral tegmental area and the locus coeruleus. glutamatergic and gabaergic projections from the amygdala to bnst are each sufficient for the development of anxious responses to unpredictable stimuli. cb 1 r activity in these projections seems essential for the shift from phasic to sustained fear responses in fear conditioning chambers, interpreted as a reminiscence of the human anxiety against unpredictable threats. 60 in the context of an established anxiogenic response, blocking cannabinoid activity in the bnst facilitates the transition from persistent to phasic freezing responses, a switch that could allow earlier reinstatement of normal anxious behavior. a cooperation between the endocannabinoid and monoaminergic systems is required for anxiety modulation. 61 at a molecular level, heterodimers composed of cb 1 r and 5-ht 2a receptors are essential for the effects of thc promoting anxiolysis and social interaction. 61 in agreement with this cannabinoid-serotonergic interaction, deleting cb 1 r from serotonergic neurons of the raphe nuclei leads to decreased social interaction and enhanced anxiety-like behavior in a novelty-suppressed feeding test. 62 close coordination between both systems has also been reported at a circuit level. cb 1 r-expressing glutamatergic neurons of the pfc synapse with serotonergic and gabaergic neurons in the dorsal raphe nuclei. optogenetic approaches have revealed that dorsal raphe gabaergic synapses are more sensitive to the inhibitory effect of cb 1 r activity than serotonergic neurons. as a consequence, cb 1 r stimulation provokes a net increase of 5-ht output from the dorsal raphe nuclei. 63 in a related circuit, cb 1 r stimulation shows opposite anxiogenic effects controlling the lateral habenula, an area that integrates stimuli from basal ganglia and limbic system and sends output signals to dopamine and serotonergic neurons of the ventral tegmental area. 64 blocking habenular cb 1 r augments proactive coping behaviors to reduce social stress and diminishes anxiety-like behavior. with cooperation between monoaminergic and endocannabinoid systems starting to be untangled, it will probably constitute an additional source of pharmacological exploitation for anxiety disorders. preexisting conditions can modify the effects of the manipulation of the endocannabinoid system on anxiety. thus, a state of low arousal allows anxiety relief after potentiation of amygdala cannabinoid neurotransmission (2-ag or anandamide), whereas high arousal conditions prevent this effect. 33 protracted consequences of cannabinoids have been revealed when administered shortly after threat exposure. thus, functional magnetic resonance imaging (fmri) in humans has shown that single thc exposures after threatening stimuli have perceptible effects 1 week later. these effects consist of decreased amygdala-pfc activity and reduced functional coupling among pfc, hippocampus, and dorsal anterior cingulate cortex, a network involved in the extinction of aversive memories. 58 thus, the anxiolytic effects of cannabinoids depend on the quality and timing of the threats and could have delayed effects on the expression or extinction of anxiety-related behavior, not detectable immediately after the treatments. age and sex of individuals are important determinants for the consequences of cannabinoid exposure on anxiety. 65 women present an increased propensity to anxiety-related disorders and biological differences in the endocannabinoid system compared with men. 65 these sex differences have been studied in animal models of anxiety. cb 1 rknockout males show a basal anxiogenic behavior that is absent in females. 66 interestingly, both sexes show anxiogenic responses after cb 1 r blockade, 66 of higher intensity in adolescent females. 67 however, mice defective in the 2-ag-synthesizing enzyme daglα show no gender differences, except for a maternal neglecting behavior inherent to the female condition. 17 exposure of pregnant females to thc 68 or to polyunsaturated fatty acids required for endocannabinoid synthesis 69 produces life-long changes on the offspring, altering the distribution and activity of neuronal populations expressing cb 1 r. prenatal thc causes male-specific effects, including disrupted long-term depression (ltd) and heightened excitability in the pfc, enhanced anxiety, and social distancing. 68 although the female offspring did not show overt behavioral changes and their pfc ltd was maintained, transcriptional modifications and a switch from cb 1 r to trpv1-mediated ltd have been found, suggesting the existence of protective mechanisms or latent alterations in females. further studies will be needed to understand the long-lasting consequences of thc exposure on the developing female brain. the possible impact of periadolescent cannabinoid exposure on anxiety levels during adulthood has been investigated. reduced anxiety has been revealed in previously exposed males, although such an anxiolytic effect is inconsistently reported in adult females. 70 thc exposure or pharmacological disruption of the endocannabinoid tone during early adolescence also provokes decreased sociability in both sexes, occasionally without evident anxiety alterations, 71,72 that may not persist in the adult age. 71, 73 however, the existence of significant modifications during a critical age for brain development demands caution with cannabinoid intake. indeed, fmri studies in humans have described long-lasting consequences of thc exposure, including increased gray-matter volume of brain temporal areas and amygdala hypersensitivity, associated with the development of anxious symptomatology. 74, 75 the effects of cannabinoid exposure may be different in individuals who suffered previous threatening experiences. thus, rodents subjected to early life stress show reduced anxiety and cognitive and social impairments after cb 1 r agonist administration during late adolescence. these effects are associated with the normalization of biochemical alterations in bla, pfc, and hippocampus of males and females. 65 additional studies will be necessary to evaluate the therapeutic possibilities of cannabinoid treatments under these particularly sensitive conditions. recent studies have allowed a better understanding of the crucial role played by the endocannabinoid system in fear, anxiety, and stress. cb 1 r located in gabaergic and glutamatergic terminals of the limbic system modulate the glutamatergic overexcitation in the amygdala, leading to fear behavior. the endocannabinoid system protects against this overactivation by downregulating cb 1 r in gabaergic terminals, and cb 1 r in glutamatergic terminals also play a complementary role to promote fear extinction. cb 1 r located in the hpa axis and the sympathetic nervous system are key components to modulate acute stress. cb 1 r activation limits hpa axis and sympathetic activation during stress, whereas glucocorticoids induce through the endocannabinoid system the activation of amygdala circuits to promote stress perception. these effects seem mediated by an enhancement of 2-ag levels and a decreased anandamide synthesis in brain areas related to emotional and cognitive responses during stress. in contrast, chronic stress exposure leads to maladaptive changes involving the endocannabinoid system that may predispose to the development of emotional disorders. on the other hand, cb 1 r located in glutamatergic and gabaergic terminals seem to play an opposite role in anxiety control. cb 1 rs in cortical glutamatergic terminals inhibit glutamate release, and their activation induces anxiolysis, whereas cb 1 r activation from the larger population of forebrain gabaergic neurons restricts the inhibitory gaba tone and mainly facilitates anxiety. this opposite role of different cb 1 r leads to complex endocannabinoid circuits to regulate anxiety, where increasing the endocannabinoid activity is mostly related with anxiolysis, although an enhanced anxiety is also mediated in particular circuits. therefore, the endocannabinoid system represents an excellent target for therapeutic purposes in emotional disorders, and the main medical reason for cannabis consumption is anxiety relief. as expected, considering the complexity of the endocannabinoid role in anxiety, anxiogenic responses are also reported after cannabis consumption together with multiple side effects, which limits the use of these cannabinoid agonists for treating emotional disorders. indeed, although self-reports of cannabis users argue acute anxiolytic consequences, the effects of chronic consumption are controversial and systematic studies are still missing. 76 indeed, chronic cannabis use has been reported to produce opposite effects in some individuals, raising the risk for the onset of anxiety disorders and the consequent enhancement in the severity of negative emotional symptoms. 76 furthermore, even though chronic cannabis use does not produce clear manifestations of physical dependence, abruptly stopping its use can trigger withdrawal symptoms, such as sleep disturbance, irritability, and anxiety. 26 in summary, additional studies are needed to determine the possible beneficial effects of modulating the activity of the endocannabinoid system for therapeutic purposes on fear, anxiety, and stress. 77 in spite of the prominent role of the endocannabinoid system in emotional disorders, we have not yet taken advantage of the therapeutic implications of this important pathophysiological mechanism. the endocannabinoid system is very widely expressed in the cns and a systemic modulation of its activity with classical ligands may not be the best pharmacological approach due to the large number of brain circuits that are affected. indeed, important side effects have been reported when the activity of the endocannabinoid system is enhanced with agonists, such as thc, or decreased with inverse agonists, such as rimonabant. the use of compounds able to modify the synthesis/degradation/reuptake of endocannabinoids 78 or biased modulators of cannabinoid receptor activity 79 could certainly provide a more appropriate strategy to obtain pharmacological responses restricted to a beneficial effect on emotional disorders. preclinical data and preliminary findings in humans obtained with these compounds suggest that indirect agonists and biased cannabinoid modulators could represent novel pharmacological tools to obtain therapeutic benefits by modifying the activity of the endocannabinoid system. n epidemiology of anxiety disorders: from surveys to nosology and back american psychiatric association. diagnostic and statistical manual of mental disorders lost in translation: how to upgrade fear memory research anatomical distribution of receptors, ligands and enzymes in the brain and in the spinal cord: circuitries and neurochemistry the endocannabinoid system in guarding against fear, anxiety and stress the neurocircuitry of fear, stress, and anxiety disorders stahl's essential psychopharmacology neuroscientific basis and practical application 4th edition the endocannabinoid system in anxiety, fear memory and habituation the endocannabinoid system and extinction learning genetic dissection of the role of cannabinoid type-1 receptors in the emotional consequences of repeated social stress in mice bimodal control of fear-coping strategies by cb 1 cannabinoid receptors dissecting the cannabinergic control of behavior: the where matters bimodal control of stimulated food intake by the endocannabinoid system neuron-type specific cannabinoid-mediated g protein signalling in mouse hippocampus short-term adaptation of conditioned fear responses through endocannabinoid signaling in the central amygdala anxiety, stress, and fear response in mice with reduced endocannabinoid levels convergent translational evidence of a role for anandamide in amygdala-mediated fear extinction, threat processing and stress-reactivity δ 9 -tetrahydrocannabinol and ethanol: differential effects on sympathetic activity in differing environmental setting activation of the sympathetic nervous system mediates hypophagic and anxiety-like effects of cb 1 receptor blockade the endogenous cannabinoid system affects energy balance via central orexigenic drive and peripheral lipogenesis rapid elevations in limbic endocannabinoid content by glucocorticoid hormones in vivo limbic system mechanisms of stress regulation: hypothalamo-pituitary-adrenocortical axis acute stress suppresses synaptic inhibition and increases anxiety via endocannabinoid release in the basolateral amygdala cannabis addiction and the brain: a review concomitant thc and stress adolescent exposure induces impaired fear extinction and related neurobiological changes in adulthood efficacy and safety of the weightloss drug rimonabant: a meta-analysis of randomised trials corticotropin-releasing hormone drives anandamide hydrolysis in the amygdala to promote anxiety role of the endocannabinoid system in the dorsal hippocampus in the cardiovascular changes and delayed anxiety-like effect induced by acute restraint stress in rats recruitment of prefrontal cortical endocannabinoid signaling by glucocorticoids contributes to termination of the stress response neurobiological interactions between stress and the endocannabinoid system brain on stress: how the social environment gets under the skin endocannabinoid system, stress and hpa axis constitutive increases in amygdalar corticotropin-releasing factor and fatty acid amide hydrolase drive an anxious phenotype fatty acid amide hydrolase inhibitors produce rapid anti-anxiety responses through amygdala long-term depression in male rodents stress-induced modulation of endocannabinoid signaling leads to delayed strengthening of synaptic connectivity in the amygdala chattarji s. stress duration modulates the spatiotemporal patterns of spine formation in the basolateral amygdala deficiency in endocannabinoid signaling in the nucleus accumbens induced by chronic unpredictable stress endocannabinoid signaling as an intrinsic component of the circuits mediating adaptive responses to repeated stress exposure in adult male sprague dawley rats endocannabinoid system and adult neurogenesis: a focused review endocannabinoid signaling collapse mediates stress-induced amygdalo-cortical strengthening how i faced my coronavirus anxiety using neuroscience to help the endocannabinoid system in fear, anxiety, and stress -maldonado et al understand fear and anxiety: a two-system framework uncertainty and anticipation in anxiety: an integrated neurobiological and psychological perspective the role of cannabis in treating anxiety adverse effects of cannabis biphasic effects of cannabinoids in anxiety responses: cb1 and gaba b receptors in the balance of gabaergic and glutamatergic neurotransmission cannabinoid cb1 receptor calibrates excitatory synaptic balance in the mouse hippocampus cannabinoid cb1 receptor in dorsal telencephalic glutamatergic neurons: distinctive sufficiency for hippocampus-dependent and amygdala-dependent synaptic and behavioral functions bidirectional regulation of novelty-induced behavioral inhibition by the endocannabinoid system circuit specific functions of cannabinoid cb1 receptor in the balance of investigatory drive and exploration a runner's high depends on cannabinoid receptors in mice chemical probes to potently and selectively inhibit endocannabinoid cellular reuptake functional redundancy between canonical endocannabinoid signaling systems in the modulation of anxiety 2-arachidonoylglycerol modulation of anxiety and stress adaptation: from grass roots to novel therapeutics influence of δ 9 -tetrahydrocannabinol on long-term neural correlates of threat extinction memory retention in humans termination of acute stress response by the endocannabinoid system is regulated through lysine-specific demethylase 1-mediated transcriptional repression of 2-ag hydrolases abhd6 and magl cannabinoid cb1 receptors in distinct circuits of the extended amygdala determine fear responsiveness to unpredictable threat cognitive impairment induced by delta9-tetrahydrocannabinol occurs through heteromers between cannabinoid cb 1 and serotonin 5-ht 2a receptors cannabinoid type-1 receptor signaling in central serotonergic neurons regulates anxiety-like behavior and sociability target-specific modulation of the descending prefrontal cortex inputs to the dorsal raphe nucleus by cannabinoids the lateral habenula directs coping styles under conditions of stress via recruitment of the endocannabinoid system cannabinoids reverse the effects of early stress on neurocognitive performance in adulthood sex-dependence of anxiety-like behavior in cannabinoid receptor 1 (cnr1) knockout mice effects of cb1 receptor antagonism and stress exposures in adolescence on socioemotional behaviours, neuroendocrine stress responses, and expression of relevant proteins in the hippocampus and prefrontal cortex in rats sex-dependent effects of in utero cannabinoid exposure on cortical function lifelong epigenetic programming of cortical architecture by maternal 'western' diet during pregnancy cannabinoid and nicotine exposure during adolescence induces sex-specific effects on anxiety-and reward-related behaviors during adulthood disrupting the endocannabinoid system in early adolescence negatively impacts sociability effect of repeated juvenile exposure to δ 9 -tetrahydrocannabinol on anxiety-related behavior and social interactions in adolescent rats effects in rats of adolescent exposure to cannabis smoke or thc on emotional behavior and cognitive function in adulthood cannabis use in early adolescence: evidence of amygdala hypersensitivity to signals of threat grey matter volume differences associated with extremely low levels of cannabis use in adolescence sartori sb, singewald n. novel pharmacological targets in drug development for the treatment of anxiety and anxiety-related disorders the potential of inhibitors of endocannabinoid metabolism for drug development: a critical review pregnenolone can protect the brain from cannabis intoxication key: cord-353592-gsvobusu authors: luceño-moreno, lourdes; talavera-velasco, beatriz; garcía-albuerne, yolanda; martín-garcía, jesús title: symptoms of posttraumatic stress, anxiety, depression, levels of resilience and burnout in spanish health personnel during the covid-19 pandemic date: 2020-07-30 journal: int j environ res public health doi: 10.3390/ijerph17155514 sha: doc_id: 353592 cord_uid: gsvobusu the number of health workers infected with covid-19 in spain is one of the highest in the world. the aim of this study is to analyse posttraumatic stress, anxiety and depression during the covid-19 pandemic. associations between burnout, resilience, demographic, work and covid-19 variables are analysed. cross-sectional data on 1422 health workers were analysed. a total of 56.6% of health workers present symptoms of posttraumatic stress disorder, 58.6% anxiety disorder, 46% depressive disorder and 41.1% feel emotionally drained. the profile of a health worker with greater posttraumatic stress symptoms would be a person who works in the autonomous community of madrid, in a hospital, is a woman, is concerned that a person he/she lives with may be infected, and thinks that he/she is very likely to be infected. the risk variables for anxiety and depression would be a person that is a woman, working 12or 24-h shifts, and being worried that a family member could be infected. high scores on emotional exhaustion and depersonalization are risk factors for mental health, with resilience and personal fulfilment being protective variables. data are provided to improve preventive measures for occupational health workers. the world health organization declared the covid-19 outbreak as a pandemic on march 11, 2020 . in europe, italy and spain were the first to report a high number of deaths, as well as a rapid increase in admissions to intensive care units (icu) of patients with symptoms associated with the disease. in may 2020, spain is one of the top five countries with the highest number of people infected, registering over 242,707 cases as of 12 june 2020, and more than 27,136 deaths [1] . in critical pandemic-related situations, research indicates that individuals experience a stress response associated with their fear of contracting the virus from contact with other people or objects. they also have symptoms of posttraumatic stress, such as intrusive thoughts, insomnia or nightmares [2] . during the epidemic of severe acute respiratory syndrome (hereinafter, sars), a high prevalence of symptoms of posttraumatic stress, anxiety and depression was identified in emergency service professionals including hyperarousal, anger, loss of motivation at work, difficulty concentrating or trouble falling asleep [3] . however, not all individuals exposed to high negative impacts or crisis situations develop such symptoms, with resilience being relevant as a protective factor [4, 5] . resilience, the individual's ability to deal with adversities as challenges, has been shown to reduce the impact of traumatic events, decreasing the likelihood of developing posttraumatic stress disorders [6] . resilience can be understood as a process of positive adaptation to a stressful situation, in which an interaction between personal resources and the environment is established [7] . resilience varies from person to person and depends on several factors, such as personality or interpersonal and social backgrounds. the strategies to cope with the current pandemic that have been identified are optimism, social support, staying actualized, avoiding information overload and maintaining online communication [8] . in healthcare personnel, a key factor for promoting resilience is to increase the sense of control over the adverse situation. for example, perceiving that disease prevention measures can be managed or controlling the possibility of protecting oneself with the resources that health care providers have around them to care for infected patients are some of the strategies that have been adopted in this pandemic [9] . in similar critical situations, such as the severe acute respiratory syndrome (sars) epidemic, nurses who have shown higher levels of confidence in infection protection and control equipment have shown lower levels of anxiety, negative mood and emotional fatigue [10] . individuals with high levels of resilience have less irritability, less concern for environmental stimuli, better interpersonal relationships, fewer headaches and musculoskeletal pains, and lower levels of depression [11] . if these symptoms persist over time, the feeling of a lack of control and uncertainty at work may increase, leading to burnout. this syndrome is related to work. it is characterized by high emotional exhaustion, high levels of depersonalization and low personal accomplishment [12] . the person may experience dysphoric symptoms, such as tiredness or emotional exhaustion. the symptoms appear in relation to work situations in individuals who previously did not show psychosocial alterations. in addition, burnout is associated with a decrease in work performance due to negative behaviors towards work [13] . in particular, in health workers exposed to traumatic situations during this pandemic, the presence of burnout has been detected, as well as a reduction in the ability to apply coping strategies or negative attitudes towards work. in addition to the symptoms of exhaustion, related to anxiety, depression or other symptoms related to physical pathologies (e.g., cardiovascular problems), burnout can lead to intention to leave the post, which would cause high costs [14] . the speed with which the disease has spread, as well as the state of confinement, has led some researchers to analyse psychological variables resulting from the situation. for example, in a recent study of the general spanish population, in which 3480 people participated, more than 20% were found to suffer from anxiety, 18.7% revealed symptoms associated with depression, and approximately 16% suffered from posttraumatic stress. in addition, female gender was associated with greater symptomatology in anxiety, depression and posttraumatic stress, while being in the older age group was related to fewer symptoms [15] . this data are similar to those obtained in a survey carried out in the general population in china, in which 1210 people participated, of which 16.5% reported moderate to severe depressive symptoms and 28.8% moderate to severe anxiety [16] . in other european countries, such as italy, the general population has shown high levels of anxiety, depression and stress, highlighting a higher prevalence in women, people with negative affect and individuals who had family members infected or had to work away from home [17] . however, despite the state of confinement, certain professional groups, as in the case of health care personnel, have performed their jobs under great stress for weeks. these professionals, together with security forces, funeral staff and others, have been highly exposed to the virus and situations with high emotional impact. they are thus more likely to suffer mental problems, especially in the first three months in which symptoms of posttraumatic stress, affective disorders, burnout or others may increase [18] . spain leads the ranking of the number of health professionals infected with covid-19 during their work. more than 40,000 health workers have tested positive for covid-19 [19] . the critical situation requires the study of the psychological state of health professionals, and the potential harm to mental health caused by their exposure during the pandemic. a recent study on stress in 958 health workers from the city of wuhan indicates that more than half had symptoms related to anxiety and depression. specifically, 54% of the total sample experienced symptoms of anxiety, and 58% of depression, with the prevalence of stress being higher than that previously detected in health professionals who had to deal with the sars virus [20] . in a study involving 1257 health workers from china, of which 760 were from wuhan, 71.5% also showed symptoms of distress, 44.6% of anxiety, 50.4% of depression and 34% of insomnia. these symptoms were more severe in nursing staff, front-line professionals and those who worked at the epicentre of the covid-19 outbreak (wuhan) [21] . similar results have been found in other european countries such as germany, where health workers, specifically nurses, have reported high levels of stress, emotional fatigue and depressive symptoms [22] . the impact of the situation on health workers may even produce symptoms of psychotic disorder, even when this is not evident in their clinical history [23] . additionally, the stress generated by the possibility of being infected with the disease also adds to the rest of the stressful conditions of these professionals. during the influenza a (h1n1) pandemic, health workers were reported to be twice as likely to be infected through contact with patients [24] . working on the front line with infected people increases the likelihood of becoming infected, especially in this group [25] . health professionals must work in extreme conditions, in situations where resources can be scarce. for example, they must take care of a high number of patients in disaster or epidemic situations, often without sufficient beds or staff [26] . in addition to their jobs in hospitals, primary care or intensive care units, they also work in nursing homes, where the disease has had a major impact in spain. some authors indicate that risk factors for infection may include: (a) factors related to organization, such as the rapid development of new tasks and procedures, a shortage of protective material, frequent equipment changes or the high risk of increased demand for care by other different pathologies, in addition to covid-19; (b) watching patients die alone; (c) fear of infecting loved ones or having to practice social distancing for an indefinite period to protect them; and (d) prioritization of care for certain patients [27] . on the basis of the above, health professionals must deal with possible psychological, work-related consequences during the covid-19 crisis, such as posttraumatic stress, anxiety, depression or burnout [28] .the aim of this study is to assess the symptoms of posttraumatic stress, anxiety, depression, levels of burnout and resilience in the spanish health workers during the covid-19 pandemic. it also aims to evaluate the relationship between each of the variables (demographic, work, covid-19, burnout and resilience) and the symptoms of posttraumatic stress, depression and anxiety. it is equally intended to identify which variables have the most weight in each of the three categories (posttraumatic stress, anxiety and depression). the main hypotheses of this study would be the following: (a) health care workers evaluated will have high levels of post-traumatic stress, anxiety, depression and burnout; (b) resilience factor will be associated with lower burnout and with symptoms related to the above three categories; (c) the female gender will be associated with symptoms of the three categories; (d) older health care personnel would have fewer symptoms; (d) health care workers in contact with other infected patients, who are highly likely to become infected and have fewer resources or protective equipment, will have more symptoms of post-traumatic stress disorder, anxiety, depression and burnout. the sample includes 1539 subjects, recruited by non-probabilistic sampling. as criteria of exclusivity, the participants had to be in contact with patients of covid-19. finally, 117 were eliminated because they were not health personnel in contact with these patients. the sample of the study was made up of 1228 women (86.4%) and 194 men (13.6%). the mean age was 43.88 (sd = 10.82, ranging between 19 and 68). the following instruments were used: demographic, job-related and variables specific to covid-19. due to the importance of understanding how the disease affects these professionals, the researchers of this study collected information related to demographic variables, associated with the job, changes of residence, possible contact with people during work, covid-19 tests, hospitalization, isolation, protective equipment, concern over becoming infected, concern that a family member and/or someone with whom they are living may be infected. posttraumatic stress: the impact of event scale-revised (ies-r) was used [29] . this scale was used to assess the emotional distress that accompanies a stressful life event. it is made up of 22 items distributed in three scales: intrusion (7 items, an example of this scale would be "i thought about it even when i did not want to"); avoidance (8 items, an example is "i tried not to think about the event"); and hyperarousal (7 items, a sample item is "i was easily startled and scared"). in relation to posttraumatic stress, a score of 20 was considered as the cut-off point. a total score greater than or equal to 20 on the ies-r is associated with a diagnosis of psychiatric disorder and a mean score less than or equal to 14 is associated with a non-diagnosis of a psychiatric disorder [30] . it shows adequate psychometric properties in its spanish adaptation, confirming the solution of the three factors mentioned and a reliability greater than 0.70 in all subscales. anxiety and depression: the spanish adaptation of the hospital anxiety and depression scale (hads) instrument was used [31, 32] . consisting of 14 items that correspond to two subscales: anxiety and depression, with 7 items each, on a likert 0-3 response scale. an example of an item in the anxiety scale is "i feel tense and nervous" and "i feel slow and awkward" in the depression scale. it evaluates symptoms of anxiety and depression in patients and in the general population. the cut-off values are between 7 and 13 possible or probable presence of a mood disorder, and greater than 14-15 for severe disorder (the range ranges from 0 to 21) for both anxiety and depression scales. accordingly, to analyse the prevalence of symptoms in this study, the variables have been categorized as follows: < 6.99 no disorder, 7-13.99 possible or probable, > 14 severe disorder. the higher the score, the greater the prevalence of symptoms of anxiety and depression. in its spanish adaptation, it has shown adequate psychometric properties, confirming the validity of two factors and an internal consistency of 0.77 in anxiety and 0.71 in the depression subscale [32] . burnout: the spanish adaptation of the maslach burnout inventory-mbi-hss instrument was applied, which assesses burnout syndrome [33, 34] . it consists of 22 items of seven response options on a likert scale from 0 (never) to 6 (every day). the cut-off points for health personnel in the spanish sample were used to analyse the prevalence of the different components of burnout in this study: emotional fatigue (low < 22, medium 22-23, high > 31); depersonalization (low < 7, medium 7-13, high > 16); and personal accomplishment (low < 30, medium 30-35, high > 35). it presents adequate psychometric characteristics, showing an appropriate fit for the three-factor solution and an internal consistency greater than 0.71 in all subscales [35, 36] . an example of an item in the emotional exhaustion scale is "i feel emotionally drained for my work", "i think i treat some people like impersonal objects" in the depersonalization scale, and "i easily understand how people feel" in the personal accomplishment scale. resilience: the spanish adaptation of the brief resilience scale (brs) was used [37, 38] . it evaluates the resilience construct, understood as the subject's ability to deal with environmental obstacles and recover from stressful circumstances. it is made up of 6 items that are answered on a likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). the higher the score, the greater the degree of resilience the person shows to deal with adversities. an example of an item in this scale is "i tend to recover quickly after going through difficult times". the spanish adaptation presents adequate psychometric properties, corroborating the single-factor solution and an internal consistency of 0.83. the approval of the deontological committee of the faculty of psychology of the complutense university of madrid (ref. pr_2019_038; 01/04/2020) was obtained before beginning the study. researchers contacted both the coordinators and trade unions of health centres to inform them of this study. due to lockdown, data were collected by means of an online survey, from 1 to 30 of april 2020, which included the instruments described above. before starting the survey, participants had to give their informed consent in order to continue. informed consent included the purpose of the study, those responsible for it and information on the confidentiality of the data, anonymity and the legal clause on personal data protection. before completing the survey submission, participants were required to respond to all items. the completion time for all items was approximately 15 min. the analyses were carried out with the spss 26 statistical package. the proportion of cases with symptoms of the disorders mentioned above was analysed. descriptive analyses (frequencies, mean, standard deviation) were performed for symptoms associated with posttraumatic stress disorder, anxiety, depression, burnout and resilience. linear regression equations were used to evaluate the relationship between each of the variables (demographic, work, covid-19, burnout and resilience) irrespective of the symptoms (posttraumatic stress, anxiety and depression), using the r 2 value and the standardized β coefficient. the objective was to calculate the impact of posttraumatic stress, anxiety and depression on each of the variables. dummy variables were used for this. finally, linear regression models were used to see which variables (demographic, work, covid-19, burnout and resilience) were jointly related to symptoms of posttraumatic stress, anxiety and depression. the model was estimated by least squares, using the forward extraction method. analyses were carried out to evaluate the proportion of health care cases with symptoms associated with possible posttraumatic stress disorder, anxiety, depression and burnout at their different severity levels. the results of both genders are shown in table 1 . there are gender differences in symptoms of post-traumatic stress disorder, anxiety and depression. in addition, there are differences between men and women in depersonalization scale of burnout. the data of internal consistency and correlations between the factors evaluated with the instruments used are represented in table 2 . regarding gender and age, being a woman is positively and significantly associated with posttraumatic stress, anxiety and depression, while age is negatively and significantly associated with symptoms of posttraumatic stress and anxiety. working outside the autonomous community of madrid and in any centre other than primary care, hospital, nursing home or day centres (other category) is negatively and significantly related to posttraumatic stress. possessing doctoral and postgraduate studies is negatively and significantly associated with anxiety and posttraumatic stress, respectively. being a member of the non-supervisory staff is positively and significantly associated with posttraumatic stress, just as being a doctor is negatively and significantly associated with symptoms of all the evaluated categories. the caregiver position is negatively and significantly associated with anxiety and depression. working a fixed shift in the afternoon is positively and significantly associated with posttraumatic stress, anxiety and depression, while working a night shift is only positively and significantly associated with posttraumatic stress. with respect to rotating shifts, the late-night shift and on-call, or 12/24 h shifts are positively and significantly associated with posttraumatic stress and depression, respectively. working part-time is positively and significantly associated with all three categories (posttraumatic stress, anxiety, and depression). having a permanent statutory (civil servant) contract and having a training contract are negatively and significantly associated with posttraumatic stress and depression, respectively. finally, the number of hours worked per week is positively and significantly associated with depression, and the number of on-call hours performed per month is positively and significantly associated with posttraumatic stress and depression (see table 3 ). changing address or living with people who are at risk is positively related to symptoms of posttraumatic stress, anxiety or depression. on the other hand, having personal protective equipment and not being very concerned that family members are infected is negatively related to symptoms of posttraumatic stress, anxiety or depression. hospitalization for symptoms of covid-19 and isolation due to possible contagion of the disease is positively related to posttraumatic stress. thinking that becoming infected with covid-19 is highly unlikely is negatively related to symptoms of posttraumatic stress and anxiety. emotional fatigue and depersonalization are positively and significantly related to symptoms of posttraumatic stress, anxiety and depression, while personal accomplishment is negatively and significantly related to symptoms of anxiety and depression. finally, resilience is associated in a negative and significant way with symptoms from all the evaluated categories. on the other hand, these professionals present moderate levels of resilience, while the highest possible score on resilience is 6, the mean score for these individuals is 3.02 (sd = 0.39), therefore indicating moderate levels. all associations can be seen in table 4 . as shown in table 5 , the posttraumatic stress symptom model was significant, explaining 39.6% of the variance (f(17, 1405) = 54,022, p < 0.001). it was also significant for anxiety symptoms, explaining 40.2% of the variance (f(12, 1412) = 78.593, p < 0.001). in relation to the depression model, it was significant, explaining 39.3% of the variance (f(14, 1408) = 64.932, p < 0.001). the variables common to the three models were emotional fatigue, depersonalization, resilience, gender, and concern that someone with whom they live could be infected. the variables positively related to posttraumatic stress are emotional exhaustion, depersonalization, working in the autonomous community of madrid, having a primary education, working in a hospital, being very concerned that someone with whom they live may become infected and thinking that there is a high risk of also becoming infected with covid-19. on the other hand, the variables negatively related to posttraumatic stress are resilience, being a man, having a doctor's degree, living with an unmarried partner, being a doctor or having another profession (mainly pharmacist or psychologist, but not a nurse, nursing assistant or caregiver), having protective equipment at work, not being concerned that someone you live with can be infected with the disease and the number of people you live with. the variables positively and significantly related to anxiety would be emotional exhaustion, depersonalization, 12-or 24-h shifts or on-call hours and being very concerned that someone with whom they live could be infected. the variables negatively and significantly related to anxiety would be resilience, being a man, being separated, working in nursing homes or day centres, being a doctor, having a rotating morning-afternoon shift and not having been isolated due to covid-19. finally, having symptoms of depression is positively and significantly related to: emotional exhaustion, depersonalization, 12-or 24-h shifts or on-call hours, the number of guards per month, being very concerned that someone with whom you live may be infected, not having a family and thinking that it is very likely that you will be infected with covid-19. the variables negatively and significantly related to depression would be personal fulfilment, resilience, being a man and having a fixed or training contract. the gender-differentiated posttraumatic stress models were significant, in both men and women, explaining 35.2% of the variance in women (f(13, 1210) = 50,667, p < 0.001) and 53.7% in men (f(9, 183) = 23,548, p < 0.001). on the anxiety scale, the models were significant, explaining 36.3% of the variance in women (f(11, 1212) = 64,280, p < 0.001) and 62.7% in men (f(6,168) = 52,066, p < 0.001). for the depression scale, the models were significant, explaining 37.73% of the variance in women (f(14, 1223) = 52.310, p < 0.001). tables 6 and 7 show the regression models of post-traumatic stress, anxiety and depression, differentiated by gender. in relation to the gender-differenciated models, in women (see table 6 ): the symptoms of posttraumatic stress are positively and significantly related to emotional exhaustion, depersonalization, working in a hospital, being very concerned that someone with whom they live may become infected and thinking that becoming infected with covid-19 is very likely. on the other hand, the variables negatively related to posttraumatic stress are personal accomplishment, resilience, living with and unmarried partner, working in nursing homes, being a doctor or having another profession (mainly pharmacist or psychologist, but not a nurse, nursing assistant or caregiver) and thinking that is very unlikely to be infected with covid-19. the variables positively and significantly related to anxiety would be emotional exhaustion, depersonalization, being very concerned that someone you live with can be infected with the disease and change of residence through fear of infecting family members. the variables negatively and significantly related to anxiety would be resilience, being separated, working in nursing homes and not being at all concerned that someone you live with can be infected with the disease. having symptoms of depression is positively and significantly related to emotional exhaustion depersonalization, being a nurse, 12-or 24-h shifts or on-call hours, those who live with people who are at risk and being very concerned over a possible infection of a family member they do not live with. the variables negatively and significantly related to depression would be personal accomplishment, resilience, being a doctor, having a fixed or training contract. in relation to the gender-differentiated models, in men (see table 7 ): the symptoms of posttraumatic stress are positively and significantly related to emotional exhaustion, having a primary education and being very concerned that someone with whom they live may become infected. on the other hand, the variables negatively related to posttraumatic stress are resilience, having a doctor's degree, not having been isolated due to covid-19 and not being concerned that someone with whom you live with can be infected with the disease. the variables positively and significantly related to anxiety would be emotional exhaustion, being a nurse and having been isolated due to covid-19. the variables negatively and significantly related to anxiety would be resilience, having a training contract and having a statutory fixed-term employment. having symptoms of depression is positively and significantly related to emotional exhaustion depersonalization and being very concerned that someone with whom they live may become infected. the variables negatively and significantly related to depression would be personal accomplishment, resilience, having a doctor's degree, having a training contract, not having been isolated due to covid-19 and not having been hospitalized for symptoms compatible with those of coronavirus. table 6 . regression models for posttraumatic stress, anxiety and depression in women (n = 1228). table 7 . regression models for posttraumatic stress, anxiety and depression in men (n = 194). this research aimed to assess the symptoms of posttraumatic stress, anxiety, depression, burnout and resilience in spanish health workers during the covid-19 pandemic. it was also aimed at evaluating the relationship between each of the variables independently (demographic, work, covid-19, burnout and resilience) and the symptoms of posttraumatic stress, depression and anxiety, as well as the variables that (together) carry more weight in each of the three categories (posttraumatic stress disorders, anxiety and depression). the results show that 56.6% of health workers present symptoms of posttraumatic stress disorder. the number having a possible anxiety disorder is 58.6%, with 20.7% having a severe disorder. equally, a high percentage, specifically 46%, would have a possible depressive disorder and 41% feel emotionally drained. in this sense, the first hypothesis would be fulfilled, although it would be necessary to make a thorough evaluation to determine a clinical diagnosis. most workers present probability of developing a posttraumatic stress disorder, anxiety or depression. during the middle east respiratory syndrome (mers) or ebola crises, among others, health professionals reported a higher number of symptoms related to posttraumatic stress [39] , so it is necessary to pay attention to the increase in these symptoms, even more so in the situation of the covid-19 pandemic that has not yet subsided. the demographic variables show that having a doctoral or postgraduate degree represent protective variables of anxiety and posttraumatic stress, respectively. in addition, lower-level workers show more symptoms of posttraumatic stress. this result may be due to the fact that, in lower-level jobs, control over procedures and decision-making capacity is lower than in other higher-level positions. some authors have shown that the main differences among professions regarding the symptomatology evaluated during the covid-19 pandemic apply to nurses and other positions, such as doctors. nurses present more symptoms of anxiety and depression [40] . these differences may be associated with the contact of these professionals with infected patients. on the other hand, being a woman is associated with greater symptoms of posttraumatic stress, anxiety or depression in the sample of health workers evaluated. younger health workers show greater levels of posttraumatic stress and anxiety. this may be due to a lack of work experience in similar stressful situations. another possible reason is that, during the current pandemic, the lack of health care staff has required that senior students or people with fewer experience have had to deal with the demands of the covid-19 patients. the data obtained in this study on the gender and age variables coincide with the findings of other studies in health personnel from different countries [41, 42] . some authors suggest that, both in the current situation due to covid-19 and in similar previous situations, symptoms of stress, anxiety and depression generally increase in health professionals and also coincide in pointing out that women present more symptoms than men do. regarding gender differences, the data obtained in this study may be due to the high number of women in positions such as nurse or nursing assistant. on the other hand, in mood disorders, which have a high comorbidity with those of anxiety, there is a high prevalence of women compared to men. for example, women present more rumination and there are hormonal differences that can explain these results [43] . variables related to jobs show that those health workers who have part-time jobs have more symptoms of posttraumatic stress, anxiety and depression. the shifts most related to psychological problems are the night, afternoon and afternoon-night rotating shifts. in this regard, similar results have been identified with health personnel that indicate the association between working the night shift and having gastrointestinal problems, hormonal problems, and changes in mood and cognitive state, among others [44] . regarding the work shift, other authors specify that there is a greater risk of having symptoms of depression as the number of days worked in the night shift increases [45] . doctors have fewer symptoms of posttraumatic stress, anxiety, or depression, and caregivers have fewer symptoms of anxiety and depression. health workers with a lower job category have more symptoms of posttraumatic stress, while those who work more hours a week have more symptoms associated with depression. health workers who do more on-call hours a month have more symptoms of posttraumatic stress and depression. therefore, the hours of rest for these professionals must be respected. in relation to the information collected on covid-19, it should be noted that the health workers who have had to change their residence due to the pandemic have been isolated due to possible contagion, and those who live with people who are at risk or think they may infect other people have more symptoms of posttraumatic stress, anxiety or depression, although these differences were not statistically significant in depression for the two variables: being isolated due to possible contagion and the likelihood of becoming infected with covid-19. regarding the hypothesis related to these variables, it would be partially fulfilled, since the association between the possibility of infection and the symptoms of depression would not be significant. recent research indicates that one of the greatest concerns of health personnel is the possibility of infecting others, especially family members [46] . believing that they are very unlikely to be infected with covid-19 is related to fewer symptoms of posttraumatic stress and anxiety. on the other hand, as proposed in the study hypothesis, those health workers who have personal protective equipment to cope with the disease have fewer symptoms of posttraumatic stress, anxiety or depression. these results may be due to the fact that, on the one hand, contact with people who may be infected is a risk factor for imminent contagion among health workers, as a result of the high transmission of the disease [47] ; on the other hand, the use of personal protective equipment is essential to be able to work and treat patients with covid-19 [48] . the profile of a health worker with greater symptoms of posttraumatic stress would be a person who works in the autonomous community of madrid, in a hospital, is a woman, has primary studies, worries that their family members may become infected and thinks that they are very likely to be infected with covid-19. the protective variables of suffering posttraumatic stress symptoms are being a man, having a doctor's degree, living with a partner (not married), being a doctor or working in "another position" (a category made up mainly of pharmacists and psychologists), having protective equipment at work, not being concerned about infecting the people with whom they live and not living alone. the risk variables associated with anxiety symptoms are being a woman, having a 12-or 24-h on-call shift and being worried that a person he/she lives with could be infected. additionally, the following protective factors have been identified: being a man, being separated, working in nursing homes or day centres, being a doctor, having a rotating morning-afternoon shift and/or not being isolated by covid-19. the profile of the health worker with greater symptoms of depression is being a woman, working 12-or 24-h shifts or on-call hours, the number of on-call hours per month, thinking that they are very likely to become infected with covid-19, being worried about infecting someone with whom they live and having no family. the protective variables of depression are being a man, having a fixed-term or training contract, feeling professionally accomplished and not living with people who are at risk. presenting high scores in emotional exhaustion and depersonalization are risk factors for posttraumatic stress, anxiety and depression. however, resilience would be a protective variable that reduces symptoms in all three disorders, and personal accomplishment would be a protective variable against depressive symptoms. one study points out that, in 2003, during the sars epidemic, health personnel showed symptoms related to posttraumatic stress disorder and, in general, higher levels of psychological stress [49] . recent research has indicated that, during the influenza a (h1n1) outbreak, resilience levels had a direct influence on the psychological health of health personnel [50] . regarding the gender-differentiated models, being a nurse is associated with symptoms of mental disorder, specifically depression in women and anxiety in men. in men, depersonalization and personal accomplishment are only associated with depression (although this relationship is not significant), while in women it is associated with the three scales of burnout. that is to say, women who have high scores in depersonalization would have more symptoms of mental disorder than men. in men, personal accomplishment would not be a protective variable, while for women it would be a protective factor for posttraumatic stress, anxiety and depression. having a primary education would be a risk variable for posttraumatic stress and having doctoral studies would be a protective variable of posttraumatic stress and depression, but only in men. in relation to the type of contract, having a statutory fixed-term employment contract is negatively related to anxiety in men, not being a relevant variable for women. the type of shift is a relevant variable for women, but not for men. specifically, 12-or 24-h shifts are positively related to depression in women, but not in men. having a fixed contract is a more relevant variable for women than for men, since it is a protective variable of depression in women. with regard to the foregoing, one of the main results of this study is that the levels of resilience of the healthcare workers evaluated are moderate. taking into account that resilience is presented as a possible protective factor of symptoms of posttraumatic stress disorder, anxiety and depression, the need to promote resilience among health personnel is highlighted. different studies have pointed out various measures to promote resilience among these professionals during the covid-19 pandemic. these include the following: providing psychological training to healthcare workers so that they can help patients and encouraging support within the organization by the network of personnel and train communication [51] . the model of intervention in psychological resilience based on peer support (battle buddies) developed by the us military should be highlighted. this model requires a close support partner as well as a designated mental health consultant to facilitate training in stress inoculation methods and to coordinate referral to the outpatient psychological consultation [52] . it might be interesting to introduce the elements mentioned in the spanish health care system to establish measures to promote resilience in possible future waves of covid-19. in this sense, the hypothesis proposed at the beginning would be fulfilled, since resilience would be a protective factor for such symptoms. in relation to burnout, it should be noted that a large percentage of these professionals have high scores in emotional exhaustion, but low in depersonalization and very high in personal accomplishment. the first study hypothesis, therefore, would be partially fulfilled, since it was expected that the workers would have low levels of personal accomplishment. this could be explained by the fact that health professionals have been intensely involved with patients in this situation, have felt valued by patients and society, and have realized the great importance of their profession, which may have had a very positive influence on their personal fulfilment. the variable with the greatest weight in the regression models is emotional fatigue. hence, preventive measures to reduce this should be implemented for these workers. emotional fatigue is the dimension that has the greatest relevance compared to depersonalization and personal fulfilment, within the burnout construct [53] . other authors have also identified high levels of fatigue and negative emotions in health personnel from emergency teams in coping with the covid-19 situation [54] . the study does have some limitations. the data were obtained using an online tool and people not familiar with the web could not be included in this study. in addition, the survey was carried out at the peak of the pandemic in spain: the continuous exposure to negative stimuli and the constant information in the media about the state of health care workers and those infected and deceased by covid-19 may have had an influence in the perception of anxiety and depression levels, due to the feeling of fear experienced [55] . furthermore, there is a high proportion of women compared to men. other studies have shown the same limitation [56, 57] . in this case, one of the main reasons for this difference is that, in many positions, such as nurses and nursing assistants, the majority of the positions are occupied by women. another limitation has to do with the cross-sectional design of the study: the pandemic has not yet finished and its influence on mental health cannot be reflected in this research, so it would also be advisable to carry out a longitudinal study that evaluates the evolution over time of the symptoms assessed in this work. on the other hand, there has not been a previous situation in spain in which there has been a lockdown, and it is likely that after its ending, the levels of experienced symptomatology will be lower. however, during the sars crisis, other authors have found that the symptoms of psychological problems after the quarantine period of the disease have lasted up to three years later [3, 58] . in the long term, the effects of posttraumatic stress disorder, anxiety and depression will depend on the possible outbreaks of covid-19. the measures currently being taken in order to adapt the work place to the new situation (such as providing protective equipment or increasing the number of healthcare professionals) are relevant for mitigating these symptoms. if the appropriate actions to protect health care providers are not taken, they may make medical errors in the future, present higher burnout levels associated with depressive symptoms, anxiety, suicidal ideation, have poorer interpersonal relationships or develop substance abuse [59] . therefore, a follow-up study along the next few months becomes necessary. this research presents a detailed description of the association between different variables and symptoms of posttraumatic stress, anxiety and depression. previous studies for spanish health professionals to evaluate these characteristics, including resilience, and its associations with the described variables, have not been found. among the main uses for this study is the description of the profiles of spanish healthcare providers that present a greater risk of suffering from post-traumatic stress, anxiety and depression, so more specific intervention measures can be designed to reduce these symptoms. on the other hand, resilience is a protective factor of the mentioned symptoms, so it would be advisable to include the promotion of resilience in the design of interventions to reduce stress, as other authors point out [60] . the information presented is relevant in order to protect the health of those who care for patients in future waves of covid-19 or similar situations. it would be useful to consider the results of this study in the design of future longitudinal research that analyse the evolution of these symptoms and the risk profiles described. european centre for disease prevention and control (ecdc) the psychology of pandemics: preparing for the next global outbreak of infectious disease the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perception, and altruistic acceptance of risk defensive responses to stressful life events associated with cancer diagnosis risk of post-traumatic stress disorder in 111 survivors the 2009 viareggio (italy) rail crash: the role of mood spectrum comorbidity resilience buffers the impact of traumatic events on the development of ptsd symptoms in firefighters resilience and mental health nursing: an integrative review of international literature psychological adjustment during the global outbreak of covid-19: a resilience perspective stress resilience during the coronavirus pandemic the relevance of psychosocial variables and working conditions in predicting nurses' coping strategies during the sars crisis: an online questionnaire survey first responders: mental health consequences of natural and human-made disasters for public health and public safety workers early predictors of job burnout and engagement burnout: 35 years of research and practice risk factors and consequences of severe burnout syndrome in icu mental health consequences during the initial stage of the 2020 coronavirus pandemic (covid-19) in spain immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china a nation survey of psychological distress among italian people during the covid-19 pandemic: inmediate psychological responses and associated factors mental health of nurses working at a government designated hospital during a mers-cov outbreak: a cross-sectional study informe sobre la situación de covid-19 en personal sanitario en españa psychological impact of healthcare workers in china during covid-19 pneumonia epidemic: a multi-center cross-sectional survey investigation factors associated with mental health outcomes among health care workers exposed to coronavirus disease psychosocial burden of healthcare professionals in times of covid-19-survey conducted at the university hospital augsburg unravelling potential severe psychiatric repercussions on healthcare professionals during the covid-19 crisis the occupational risk of influenza a (h1n1) infection among healthcare personnel during the 2009 pandemic: a systematic review and meta-analysis of observational studies the psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope public mental health crisis during covid-19 pandemic mental health care for medical staff in china during the covid-19 outbreak rugulies, r. the covid-19 (coronavirus) pandemic: consequences for occupational health the impact of event scale-revised propiedades psicométricas de la escala revisada del impacto del evento estresante (ies-r) en una muestra española de pacientes con cáncer. análisis y modificación de conducta the hospital anxiety and depression scale propiedades psicométricas de la escala hospitalaria de ansiedad y depresión (had) en población española maslach burnout inventory manual a meta-analytic reliability generalization study of the maslach burnout inventory evidence for factorial validity of maslach burnout inventory and burnout levels among health workers the brief resilience scale: assessing the ability to bounce back reliability and validity of the brief resilience scale (brs) spanish version survivors of covid-19 are at high risk of posttraumatic stress disorder prevalence of depression, anxiety, and insomnia among healthcare workers during the covid-19: a systematic review and meta-analysis depression, anxiety and symptoms of stress among hong kong nurses: a cross-sectional study post-traumatic stress disorder among medical personnel after nepal earthquake affective disorders and gender differences night shift work in resident physicians: does it affect mood states and cognitive levels? night shift work and risk of depression: meta-analysis of observational studies supporting the health care workforce during the covid-19 global epidemic the origin, transmission and clinical therapies on coronavirus disease 2019 (covid-19) outbreak: an update on the status world health organization-who. director-general's opening remarks at the media briefing on covid-19 psychological impact of sars survivors: critical review of the english language literature resilience training for hospital workers in anticipation of influenza pandemic the role and response of palliative care and hospice services in epidemics and pandemics: a rapid review to inform practice during the covid-19 pandemic rapid deployment of a psychological resilience intervention for health care workers during the covid-19 pandemic the role of psychosocial working conditions on burnout and its core component emotional exhaustion-a systematic review provider burnout and fatigue during the covid-19 pandemic: lessons learned from a high-volume intensive care unit for the greater good? 2 the devastating ripple effects of the covid-19 crisis knowledge, attitudes, and practices towards covid-19 among chinese residents during the rapid rise period of the covid-19 outbreak: a quick online cross-sectional survey understanding knowledge and behaviors related to covid-19 epidemic in italian undergraduate students: the epico study understanding, compliance and psychological impact of the sars quarantine experience burnout and posttraumatic stress disorder in the coronavirus disease 2019 (covid-19) pandemic: intersection, impact, and interventions resilience and emotional support in health care professionals during the covid-19 pandemic this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-350000-eqn3kl5p authors: drissi, nidal; ouhbi, sofia; janati idrissi, mohammed abdou; ghogho, mounir title: an analysis on self-management and treatment-related functionality and characteristics of highly rated anxiety apps date: 2020-07-30 journal: int j med inform doi: 10.1016/j.ijmedinf.2020.104243 sha: doc_id: 350000 cord_uid: eqn3kl5p background and objective: anxiety is a common emotion that people often feel in certain situations. but when the feeling of anxiety is persistent and interferes with a person's day to day life then this may likely be an anxiety disorder. anxiety disorders are a common issue worldwide and can fall under general anxiety, panic attacks, and social anxiety among others. they can be disabling and can impact all aspects of an individual's life, including work, education, and personal relationships. it is important that people with anxiety receive appropriate care, which in some cases may prove difficult due to mental health care delivery barriers such as cost, stigma, or distance from mental health services. a potential solution to this could be mobile mental health applications. these can serve as effective and promising tools to assist in the management of anxiety and to overcome some of the aforementioned barriers. the objective of this study is to provide an analysis of treatment and management-related functionality and characteristics of high-rated mobile applications (apps) for anxiety, which are available for android and ios systems. method: a broad search was performed in the google play store and app store following the preferred reporting items for systematic reviews and meta-analysis (prisma) protocol to identify existing apps for anxiety. a set of free and highly rated apps for anxiety were identified and the selected apps were then installed and analyzed according to a predefined data extraction strategy. results: a total of 167 anxiety apps were selected (123 android apps and 44 ios apps). besides anxiety, the selected apps addressed several health issues including stress, depression, sleep issues, and eating disorders. the apps adopted various treatment and management approaches such as meditation, breathing exercises, mindfulness and cognitive behavioral therapy. results also showed that 51% of the selected apps used various gamification features to motivate users to keep using them, 32% provided social features including chat, communication with others and links to sources of help; 46% offered offline availability; and only 19% reported involvement of mental health professionals in their design. conclusions: anxiety apps incorporate various mental health care management methods and approaches. apps can serve as promising tools to assist large numbers of people suffering from general anxiety or from anxiety disorders, anytime, anywhere, and particularly in the current covid-19 pandemic. education, and relationships [4, 2] . the exact causes of anxiety disorders are still unknown. according to the national institute of mental health, it is likely to be a combination of genetic and environmental factors [5] . other possible factors that can lead to susceptibility include brain chemistry, personality type, exposure to certain mental and/or physical disorders, trauma and stress [6] . the covid-19 outbreak, in addition to being a public health emergency, is also affecting mental health in individuals on a global scale causing people to suffer from stress, anxiety, and depression [7, 8] . the pandemic is also triggering feelings of fear, worry, sadness, and anger [9, 10] . quarantines, self-isolation, fear of the unknown, loss of freedom and other factors are causing psychological issues in people around the world [11, 12] . these situations and circumstances can trigger several anxiety disorders, mainly separation anxiety disorder which is defined as fear of being away from home or loved ones, illness anxiety disorder which is defined as anxiety about a person's health (formerly called hypochondria) [2] and panic attacks that are affecting a large number of people because of excessive worrying. psychiatric patients are additionally at a higher risk of experiencing symptoms related to psychological issues caused by the pandemic [13] . people with preexisting anxiety disorders are showing aggravation of their conditions, for example, many people with ocd are developing new fixations on the covid-19 virus and are experiencing compulsive cleaning [9] . due to the covid-19 pandemic, social interactions have significantly decreased in several parts of the world. while this may have provided relief to some people with social anxiety, it is possible this lack of interaction may have negative consequences in the longer term [14] . returning to work after a period of lockdown, while still in the state of pandemic, is also causing the workforce to exhibit symptoms related to ptsd, stress, anxiety, depression and insomnia [15] . the current covid-19 situation is also affecting the mental well-being of health care workers, who are at a high risk of psychological distress [16] , especially those who are experiencing physical symptoms [17] . the situation is further worsened by the recommended avoidance of inperson contact and fear of infection, as people with anxiety and other mental disorders might not be able to consult with a mental health professional. there are various barriers to mental health care delivery, such as cost, stigma, lack of mental health care professionals, and distance from health care services [18, 19] . mobile mental health or m-mental health, which uses mobile technologies for providing mental health services, has the potential to help overcome mental health care delivery barriers, as it provides anonymous access to care, low to no cost care, and remote communication. smartphones can be a convenient tool to reach a large number of people from different parts of the world. there are many mobile applications (apps) for mental health problems such as ptsd [20, 21] , stress [22] , depression [23] and alcohol dependence [24] , as well as other health issues such as obesity, that apps can help with, especially due to lack of exercise during circumstances similar to the current lockdown [25] . smartphone apps have high rates of acceptance among the general public, and especially in young people [26] due to its cost effectiveness [27] . many studies have reported that apps have shown positive results in the treatment and management of anxiety [28, 29, 30] . this study aims to analyze the functionality and characteristics of highly 5 j o u r n a l p r e -p r o o f rated anxiety apps to identify users' preferred features and management methods delivered for anxiety with a smartphone or a tablet. for the purposes of this study, only free apps were selected, as recent statistics in march 2020 showed that 96.3% of android apps and 90.84% of ios apps were freely available worldwide [31] . a total of 167 apps, 123 android apps, and 44 ios apps were selected. the anxiety management approaches used in these apps among other aspects of functionality have been extracted and analyzed. this section presents the methodology that was followed in order to select and analyze android and ios anxiety apps. this paper follows the quality reporting guidelines set out by the preferred reporting items for systematic reviews and meta-analysis (prisma) group to ensure clarity and transparency of reporting [32] . google play repository and the app store were used as sources to select anxiety apps. both app repositories are very popular with a high number of available health care apps: more than 41,377 apps are available in the google play store, and more than 44,384 apps are available in the app store [33] . a general search string, composed of only one word "anxiety", was used. it was automatically applied to the titles and descriptions of android and ios apps. j o u r n a l p r e -p r o o f each app from the search result was examined by the first author to decide whether or not to be included in the final selection. the second author revised the final apps selection. the following inclusion criteria (ic) were applied: • ic1: anxiety related apps in google play store and app store. • ic2: apps that have a free version. • ic3: apps that have 4+ stars rating. ic3 reflects a level of user satisfaction with the app. the focus is on highly rated anxiety apps so as to discover the functionality features and characteristics that provide high user satisfaction. the following exclusion criteria (ec) were applied to the candidate apps to identify the final selection that would be included in this study: • ec1: apps that have less than 5 raters. • ec2: apps that could not be installed. • ec3: apps that crashed and could not be used after installation. apps that match any of the ec were excluded from the selection. ec1 is based on the heuristic guideline by nielsen [34] , which recommends having five evaluators to form an idea about the problems related to usability. the apps' selection process was established as follows: 1. the search string was used to identify candidate apps in the google play store and app store in order to create a broad selection from which to choose from. 2. ic were used to identify relevant apps. 3. apps that met one or more of the ec were excluded. the above actions were carried out in march 2020. a final selection of 123 android apps and 44 ios apps was identified after application of ic and ec. fig. 1 presents the selection results. data collection was carried out using the data extraction form presented in table 1 . each app was installed and assessed to explore its functionality features and characteristics. the devices used for the apps' assessment were: oppo a9 (android 9), and ipad 3 (ios 13). a template was designed in an excel file to provide basic information about the apps as well as specifying their main features and functionality characteristics. some of these characteristics and functionality features were retrieved from the app's description available in the app repository. this section presents and discusses the results of this study. a total of 167 apps, 123 android apps, and 44 ios apps were identified as both free and highly rated apps. tables a.11, a.12, a.13, a.14, a.15 and a.16 in appendix present general information about the apps such as name, link, rating, number of raters, number of installations (not available for ios apps), and date of latest update. the majority of the selected apps (68%) offer in-app purchases for paid features and functionality. these apps are free to download and use, but many of their proposed functionality features are not available without purchase. thus, it can be said that users may not fully benefit from the app unless they purchase these specific features. however, it should also be noted that in-app purchases are a way for many developers to monetize their work 9 j o u r n a l p r e -p r o o f apps general information: -name of the app. -date of the latest update. -users rating (scored out of 5): to report the level of user satisfaction from the apps. -number of raters: to report the number of raters satisfied with the app. -number of installations (not available for ios apps): to identify the most installed apps. -in-app purchase: to identify whether free apps charge users for certain functionality features. -management method: to identify management and treatment methods for anxiety that could be delivered through an app, and the most used ones in the available apps. -intervention approach: to identify approaches that could be transmitted through an app, and the most followed approaches in the available apps. -targeted mental problem/symptoms: to identify anxiety related issues addressed by the apps and issues that might be managed with similar management methods and approaches as ones for anxiety, as well as to identify problems that could be treated and managed through apps. -involvement of mental health care professional: this information was extracted from apps' descriptions in-app repositories and from apps' content. we consider mental health care professionals to be those professionals with a mental health background including psychiatrists, therapists, counselors and experts in psychological issues or management methods. -physical health information such as hr and bp: to identify whether the app relies on physical indicators to assess the mental status of the user. -authentication method: to identify if the app provides users with the option to keep their personal health data inaccessible to other users of the same device. -gamification features: to identify whether gamification features are included in the app to encourage and motivate the users to keep using it. -social features which might include: links to communities, associations, and centers; interoperability with other apps or websites; the possibility to share content via social networks (sn); and contact information in case of emergencies. -languages: identify the availability of the apps in multiple languages, which reflects the degree of internationalization of the app. -offline availability: identify whether the app can be used without internet access. [35] . the free version of the app is used by many developers as an advertisement tool to attract users into purchasing and unlocking more features [35] . free apps with in-app options are becoming the norm in-app markets. in 2013, in-app purchases accounted for more than 70% of ios app revenue in the us and 90% of revenue in asia [36] . the majority of the selected apps (64%) updated their functionality and content in the three first months of 2020. this could be linked to the current covid-19 pandemic situation. on december 31st, 2019 the who china office was informed of a number of pneumonia cases from an unknown cause, that were later linked to the coronavirus [37] , which has now spread to all regions of the world [38] . to limit the spread and risk of the virus, the who advised the public to practice social distancing and to stay home [39] . many countries have declared obligatory lockdowns and people were quarantined, which has created a state of fear and worry that has elevated many individuals' anxiety and stress. various existing anxiety apps have, thus, been updated to include covid-19 related content. table 2 presents various management methods identified in the selected anxiety apps with meditation and breathing exercises being the most common. the main goal of meditation is to help the user enter a deep state of relaxation or a state of restful alertness. it helps to reduce worrying thoughts, which play a key role in symptoms of anxiety, and bring about a feeling of balance, calmness, and focus [40] . several studies have presented evidence supporting the use of meditation in anxiety treatments [41, 42, 43] . one study reported that it was beneficial for a group of chinese nursing students 11 j o u r n a l p r e -p r o o f meditation a1, a8, a9, a10, a13, a16, a18-a21, a23, a25, a30, a33-a37, a40, a41, a44, a56, a59, a62, a66, a67, a70, a82, a86, a92, a98, a105, a106, a111, a121, i1, i2, i6-i10, i11, i13, i16, i18, i23, i25, i29, i30, i32, i34, i40, i42 54 breathing exercises a3, a6, a20, a21, a23, a25, a29, a30 a34, a37, a41, , i29 i33 i7 i9 31 games a31, a32, a43, a46, a51, a58, a60, a63, a65, a84, a96, a101, a112, a119, a120, i12, i14, i15, i17, i20-i22, i24, i27, i28, i31, i36-i39, i41, i43, i44 33 assessment tests a117, a12, a33, a34, a48, a66, a69, a70, a72, a78, a79, a88, a91, a103, a113, i19, i7 17 stories a8, a18, a30, a36, a49, a59, a82, a98, a118, i8, i9, i18, i29, i30, i32, i42 16 mindfulness practices a10, a12, a20, a25, a56, a98, a111, a115, i2, i6, i7, i11, i19, i23, i29, i30 16 guided relaxation a22, a23, a33, a34, a40, a42, a54, a103, a111, a115, i13, i16, i8, i9 14 community chats with app users via the app a8, a25, a27, a50, a61, a63, a78, a85, a119, a123,i19 11 yoga and physical exercises a1, a2, a5, a8, a28, a30, a47, a48, a55, a59, a77, a95, a102, a108, a116, a119, i11 17 motivational and inspirational statements a16, a44, a47, a63, a72, a74, a76, a78, a81,i5, i26, i33 12 online therapy and coaching a18, a26, a27, a34, a50, a89, a90, a92 i19, i35 10 recommending activities and tips a42, a64, a66, a100, a102, a108, a113, a120,i19 9 interactive messaging a17, a18, a48, a49 4 in reducing anxiety symptoms and lowering systolic bp [44] . another study reported that it showed improvements in the reduction of anxiety for breast cancer patients [45] . a meta-analysis of controlled trials for the use of meditation for anxiety also reported a level of efficacy of meditative therapies in reducing anxiety symptoms [46] . additionally, meditation has been shown to be effective in managing various types of anxiety such as panic disorder and agoraphobia [41] . breathing exercises are another mechanism that can help to relax and relieve stress. while practicing deep breathing, a message is sent to the brain to calm down and relax. biochemical changes subsequently decrease hr and bp and help the person to relax [47] . studies have shown that breathing exercises can improve cognition and overall well-being [48] , while also reducing anxiety [48, 49, 50, 51, 52] . breathing exercises can also have a positive impact on psychological distress, quality of sleep [49] , depression [50, 51, 52] , everyday stress, ptsd, and stress-related medical illnesses [50, 53] . breathing exercises are also used to help with asthma, which was the case in a3 and a6. however, it should be noted that such exercises may help patients whose quality of life is impaired by asthma, but they are unlikely to reduce the need for anti-inflammatory medication [54] . many of the selected apps provided educational content about anxiety and other mental issues, symptoms, and management methods, either in the form of courses, articles, videos, or others. educating users about anxiety can help to reassure them and provide them with the necessary knowledge by answering questions and correcting misinformation that they might have. educating users about the provided management method and its benefits may also increase their trust in the management approach and their willingness to try it. mental assessment tests have been provided by some apps to give the user an idea about his/her mental status, anxiety, stress and/or depression levels. relaxing music and sounds, is a noninvasive and free of side-effects ap-proach that has been used in 31 apps as a management method. it has been shown to be an effective tool for the reduction of anxiety, stress, and depression [55, 56] . it has also shown positive results in the prevention of anxiety and stress-induced changes like hr and bp [57] . developers should take into account the type of music and sounds used, as well as the accompanying environment, as they both affect the effectiveness of this method [58, 59] . thirty-one apps provided journaling and writing diaries to help users plan their day, track their mood, and express their thoughts, feelings, and emotions. securing the privacy and confidentiality of users' information is critical in such apps. all selected ios apps providing journaling provide authentication methods, while only 41% of android apps with this functionality provide users with the same level of authentication. eleven apps provide the user with the possibility of communicating with other users. in these apps, users are able to share their experiences, talk about their issues, help each other, and relate to others who are undergoing similar problems as their own. in the current covid-19 pandemic, being in a state of isolation but having the ability to connect with an online community can be very helpful. the idea of enabling interaction with a community of people with similar issues is quite interesting and can be extremely helpful, especially given that people with anxiety often tend to avoid direct communication [60] . for users who prefer communication with mental health care professionals, there are ten apps available that provide online therapy and coaching, enabling users to communicate with mental health care professionals, without having to travel, while also avoiding obstacles like stigma and distance. selected apps offering online therapy services charge fees for these services. these apps also provide information on the mental health care professionals' credentials. this information is important as it allows the user to check whether these professionals are appropriately accredited and decide which mental health care professional is most suited for his/her needs. thirty-three apps provide users with games like coloring books, puzzles, and slime simulations, as management methods for anxiety. these games help the user to relax, and to take his/her mind off worrying thoughts or feelings. games are usually enjoyable and entertaining and this may motivate users to continue using these apps. the variety of management methods identified in the selected apps points to the high potential of apps usage for coping with anxiety. developers have integrated various promising and effective management methods in their apps' functionality features. users can access these features at any time and in any place. this could be beneficial for users with anxiety disorders, especially in situations where immediate help is needed (e.g., during panic attacks), or in cases where mental health care professional cannot be reached due to circumstances like distance or the current global lockdown situation. table 3 presents the selected apps which state the use of specific intervention approaches for anxiety management. the most used ones included mindfulness, cognitive behavioral therapy (cbt), and hypnosis. mindfulness was the most adopted management approach. it is defined as "bringing one's complete attention to the present experience on a moment-tomoment basis" [61] . mindfulness practices allow practitioners to shift their concentration to their internal experiences occurring in each moment, such as anxiety and mood problems [65, 66] , and improving an individual's internal cognitive, emotional, and physical experience [67] . some findings suggest that mindfulness can be more complicated than it might seem, as many el-ements like attention emotional balance, differences in emotion-responding variables, and clinical context can influence its effect [68, 69, 70] . therefore, these elements should be taken into account while developing mindfulnessbased anxiety apps. cbt is a form of psychological treatment, mainly based on efforts to change thinking patterns [71] . many studies have supported the effectiveness of cbt-based interventions for the treatment of anxiety, and have reported on the long-term positive effect it has on both children and adults [72, 29] . a study examining available evidence on cbt have yielded positive results and confirmed its effectiveness for anxiety disorders [73] . cbt has also been used in the treatment of some specific anxiety disorders like ptsd [74] and ocd [75] . it has also been proved effective for depression, alcohol and drug use problems, eating disorders, and severe mental illness [71] . cbt and mindfulness-based therapy can also be useful in reducing anxiety during the covid-19 pandemic [76] . hypnosis is a therapeutic technique designed to bring relaxation and focus to the mind [77] . many studies have reported the effectiveness of hypnosis for the treatment of anxiety. one study stated that it can reduce anxiety among palliative care patients with cancer [78] , and another reported on its considerable benefits to terminally ill patients [79] . hypnosis is also used to treat and manage stress and phobias [80] , as well as sleep and physical symptoms [78] . other approaches have also been identified in the selected apps as shown in table 3 , but it should be noted that a few of them were not based on scientific approaches. table 4 presents the different health issues besides anxiety that were addressed by the selected apps. all selected apps addressed general anxiety. some apps addressed specific types of anxiety like social anxiety, separation anxiety, performance anxiety, ocd, ptsd, and panic attacks. focus and concentration a6, a11, a20, a29, a38, a86, a112, i1, i13, i18 10 self-esteem and confidence a18, a20, a21, a83, a88, a118, a121, i1, i2, i5, i18, i26 12 pain a12, a13, a37, a49, a64, a83, a107, i18, i23 9 mood a5, a14, a18, a39, a69, a77, a89, a95, a120 9 some apps addressed other mental and physical issues, which usually occur with anxiety like stress [80, 53] , sleep issues [78] , and depression [71, 41, 53] . some apps used management methods to treat addiction-related issues, eating disorders [71] , phobias, [80] , and asthma [54] . the majority of the apps do not use physical health information. hr and bp are impacted by anxiety and stress [57] . both can be used by apps to indicate the anxiety level of the user [20] . yet in our selection only two apps provided this functionality feature (a6 and a113). a113 collects data on hr variability, using the photoplethysmogram (ppg) technique to get insights on the user's health, including stress, energy, and productivity levels. the app also allows the user to manually enter bp as a convenient way of journaling. it should be noted that a6 provides cardiovascular tests, including hr and peripheral blood circulation, as an app purchase option. only 19% of the selected apps reported involvement of mental health care professionals as presented in table 5 . apps providing online therapy specified information about the therapists that the user can contact. this information includes their specialty, experience, and diplomas. some apps shown in table 5 provided names of the professionals involved in their co-creation. providing names gives the user the possibility to look online for the credentials of the involved professionals and might increase the user's trust toward these apps. we cross-checked the names displayed in table 5 and found them to be legitimate. table 5 table 6 presents the authentication methods identified in the selected apps. the majority of the selected apps (66%) do not require authentication. the absence of authentication might give the user a sense of anonymity. however, authentication can help the user ensure the privacy of his/her data. the app a97 requests a nickname and a password, ensuring security and confidentiality as well as keeping the anonymity of the user, since it does not use any information or sources that could reveal the identity of the user like facebook account, google account, or email. nickname and password a97 1 gamification is the use of game elements in non-gaming systems which are mainly used to improve user experience and user engagement [81] . table 7 presents the different gamification methods identified in the selected apps. note that some apps use more than one gamification method. the majority of the selected apps used gamification features to encourage and motivate the user. creating a fun, interactive user experience with the adoption of game elements can create an enjoyable user experience, which can further reduce boredom and motivate users keep using the app. this can also increase user engagement, leading to users providing more accurate information about their mental health status and to increased benefit for the user from the provided mental health care management method. gamification is a widely used approach that has shown effectiveness with anxiety and other mental health problems, such as depression and ptsd for military personnel [82, 83] , and aggression for veterans [84] . combining j o u r n a l p r e -p r o o f game a31, a32, a43, a46, a51, a58, a60, a63, a65, a72, a84, a96, a101, a112, a119, a120, i14, i15, i17, i20-i22, i24, i27, i28, i31, i36-i39, i41, i43, i44 33 graphics a3, a6, a29, a30, a37, a41, a55, a59, a70, a73, a76, a80, a83 unlocking new features a114, a17, i18, i33, i7 5 score and points a27, a48, a54, i8 4 stickers, awards and stars a14, a16, a20, a100, i11 5 game elements and knowledge on game players' behaviors with known mental health care management methods is an interesting approach that can result in the creation of effective anxiety apps. table 8 presents the different social features provided by the selected apps. many apps provide social and communication features, which allow the user to connect with communities of app users as well as with centers and associations, or with others to share content and progress. those social features could prove to be beneficial to the user. for instance, sharing progress and content from the app via social networks (sn) and emails helps provide social support to the user from family and friends. social support is significantly associated with well-being and absence of psychological distress [85] . it has a favorable effect on certain psychological issues [86] , and can serve as a mediator to stress and anxiety caused by life events [87] . providing social support is also among the behavioral change techniques implemented in m-health apps to promote app usage [88] . additionally, providing contacts in case of emergencies is crucial and might help the user in critical situations 23 j o u r n a l p r e -p r o o f where he/she feels the need for immediate help. links to associations, websites, and centers can provide the user with more helpful resources. social features are very important as they help the user connect with others in a beneficial way. emergency contacts' information a12, a120, a34, a40, a54, a61, a63, a76, a91 9 group treatment i34, i35 2 table 9 presents the languages available in the selected apps. the majority of the apps (127 app) are available only in english, which can be explained by the fact that the search string applied in app repositories was in english. only one app (a98) automatically translates its content to the device's preferred language. while the rest of the apps are available in more than one language. availability in multiple languages can help reach a larger number of users. i2, i4-i7, i9, i10, i11, i13, i14, i16, i21, i23-i26, i29-i35, i37, i38, i40-i44 129 more than one language a1, a2, a6, a8, a10, a14-a16, a30, a34, a37, a44, a46, a58-a60, a62, a85, a88, a89, a101, a113, a120, i1, i3, i8, i12, i15, i17-i19, i20, i22, i27, i28, i36, i39 37 system's languages a98 1 j o u r n a l p r e -p r o o f table 10 shows whether an app requires internet access to function or not. internet access is required to install and create accounts for all apps, but once that is done, many apps function without internet access. offline availability is an aspect that will help users benefit from the app without necessarily being in a setting with internet access. this will decrease the app's limitations and make it more accessible to users. however, some of the management methods identified do require internet access, like online therapy and communication with communities of app users. additionally, offline availability may require downloading more data that could be permanently stored, which may affect a phone's memory and performance. some apps were only partially available offline, resulting in limited functionality when internet access was not available. other apps only made downloaded data available offline, meaning the user chooses and downloads content that he/she wants to be available while offline. these are convenient solutions to offline availability that do not compromise on app functionality. this study is subject to limitations, such as: (i) missing terms (e.g., stress, depression) in the search string that might have resulted in the selection of relevant apps, as usually an app targets more than one mental health issue. however, the search string used identified any app that mentions anxiety in its title and/or description, therefore this can alleviate the threat of missing relevant apps; and (ii) the first author conducted the search and applied the ec and ic to the initial selection. however, the final selection has been reviewed by the second author. with the current development in mobile communication and the wide ownership of mobile devices, m-mental health seems to be one of the most promising ways to deliver care to people in need regardless of their situation. under certain circumstances like the current covid-19 pandemic, the use of mobile communication and apps for anxiety might become a necessity. panic attacks can mimic covid-19 symptoms, which might worsen the condition of people with anxiety disorders [89] . having an app on hand that can ease anxiety in such circumstances is useful. this study highlights the functionality and characteristics of anxiety apps that are well rated by users. we plan to build on the reported findings to develop a reusable requirements catalog for anxiety apps. mental health care professionals and people with anxiety disorders will be involved in the co-creation of this catalog. the catalog will also include software quality requirements based on the iso/iec 25020 standard and recommendations from the uk national health service (nhs) and the health insurance portability and accountability act (hipaa) on health apps. since the reusable requirements catalog for anxiety apps will be based on functionality of existing highly rated apps, as well-being based on inputs from mental health care professionals and people suffering from anxiety, it could be used to assist developers to select relevant requirements for anxiety apps. apps could therefore be designed based on the catalog to assist people dealing with anxiety. requirements from the catalog could also be used to generate checklists for audit and evaluation purposes [90] , either to evaluate apps or to compare their functionality and characteristics. the findings from this study may also assist researchers and developers interested in the field of m-mental health, especially in the sub-field of anxiety, to have an overview of the characteristics and functionality of existing highly rated apps for anxiety. our findings could also assist mental health professionals to find anxiety apps that could be integrated in their mental health care process, as well as assist people suffering from anxiety to find mobile apps best suited for their needs. during the covid-19 pandemic, mhealth can also help disseminate health information among health personnel and community workers [91] . all authors contributed to the creation of the manuscript. nd: design, conception, acquisition and interpretation of data, classification of selected apps, drafting of the manuscript, revision. so: design, conception, statistij o u r n a l p r e -p r o o f what was already known on the topic: -anxiety disorders are a common mental issue. -there are many barriers to mental health care delivery, mainly cost, stigma and distance from health professionals. -apps were found to be effective tools to deliver mental health care, and overcome the aforementioned barriers. what this study added to our knowledge: -167 free and high-rated anxiety apps were analysed: 123 android apps, and 44 ios apps. -anxiety apps addressed other health issues, such as: stress, depression, sleep issues, and eating disorders. -anxiety apps adopted various management, treatment and coping approaches such as, meditation, breathing exercises, mindfulness and cognitive behavioral therapy. cal support, interpretation of data, drafting of the manuscript, critical revision. maji and mg: critical revision. all authors read and approved this manuscript. the authors have no conflict of interest. this article does not contain any studies with human participants or animals. j o u r n a l p r e -p r o o f what to know about anxiety everything you need to know about anxiety share of the population worldwide who suffered from anxiety disorders from what are anxiety disorders? anxiety causes immediate psychological responses and associated factors during the initial stage of the 2019 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 anxiety on rise due to coronavirus, say mental health charities mental health considerations during covid-19 outbreak the psychological impact of quarantine and how to reduce it: rapid review of the evidence how to manage stress and anxiety from coronavirus (covid-19 do psychiatric patients experience more psychiatric symptoms during covid-19 pandemic and lockdown? a case-control study with service and research implications for immunopsychiatry how the covid-19 pandemic affects people with social anxiety is returning to work during the covid-19 pandemic stressful? a study on immediate mental health status and psychoneuroimmunity prevention measures of chinese workforce a multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid-19 outbreak barriers to mental health care: perceived delivery system differences barriers to mental health treatment: results from the who world mental health surveys mobile apps for post traumatic stress disorder gamification-based apps for ptsd: an analysis of functionality and characteristics gamification in stress management apps: a critical app review a systematic review of cognitive behavioral therapy and behavioral activation apps for depression the alcohol tracker application: an initial evaluation of user preferences online and smartphone based cognitive behavioral therapy for bariatric surgery patients: initial pilot study receptiveness and preferences of health-related smartphone applications among vietnamese youth and young adults enabling psychiatrists to be mobile phone app developers: insights into app development methodologies adding a smartphone app to internet-based self-help for social anxiety: a randomized controlled trial effectiveness of an app for reducing preoperative anxiety in children: a randomized clinical trial adoption of mobile apps for depression and 40 f anxiety: cross-sectional survey study on patient interest and barriers to engagement statista. free and paid app distribution for android and ios 2020 the prisma statement for reporting systematic reviews and metaanalyses of studies that evaluate health care interventions: explanation and elaboration number of mhealth apps available in the apple app store from 1st quarter 2015 to 3rd quarter 2019 how to conduct a heuristic evaluation effect of perceived value and social influences on mobile app stickiness and in-app purchase intention how the most successful apps monetize their user bade novel coronavirus (2019-ncov) situation report-1 coronavirus disease 2019 (covid-19) situation report-95 coronavirus disease (covid-19) advice for the public effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders effects of meditation on psychological and physiological measures of anxiety meditation therapy for anxiety disorders a randomized controlled trial of the effects of brief mindfulness meditation on anxiety symptoms and systolic blood pressure in chinese nursing students effects of meditation on anxiety, depression, fatigue, and quality of life of women undergoing radiation therapy for breast cancer meditative therapies for reducing anxiety: a systematic review and meta-analysis of randomized controlled trials stress management: breathing exercises for relaxation effect of short-term practice of pranayamic breathing exercises on cognition, anxiety, general well being and heart rate variability impact of jacobson progressive muscle relaxation (jpmr) and deep breathing exercises on anxiety, psychological distress and quality of sleep of hospitalized older adults sudarshan kriya yogic breathing in the treatment of stress, anxiety, and depression: part i-neurophysiologic model effects of a relaxation breathing exercise on anxiety, depression, and leukocyte in hemopoietic stem cell transplantation patients effectiveness of controlled breathing techniques on anxiety and depression in hospitalized patients with copd: a randomized clinical trial self-regulation of breathing as a primary treatment for anxiety breathing exercises for asthma: a randomised controlled trial effect of music on anxiety, stress, and depression levels in patients undergoing coronary angiography buela-casal, acute stress recovery through listening to melomics relaxing music: a randomized controlled trial relaxing music prevents stress-induced increases in subjective anxiety, systolic blood pressure, and heart rate in healthy males and females effects of relaxing music on cardiac autonomic balance and anxiety after acute myocardial infarction relaxing music for anxiety control bridging differences: effective intergroup communication mindfulness and meditation wherever you go, there you are: mindfulness meditation in everyday life skills training manual for treating borderline personality disorder mindfulness training as a clinical intervention: a conceptual and empirical review the effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review mindfulness meditation, anxiety reduction, and heart disease: a pilot study mindfulness and anxiety disorders: developing a wise relationship with the inner experience of fear how does mindfulness reduce anxiety, depression, and stress? an exploratory examination of change processes in wait-list controlled mindfulness meditation training affective reactivity mediates an inverse relation between mindfulness and anxiety mindfulness and emotion regulation in depression and anxiety: common and distinct mechanisms of action what is cognitive behavioral therapy? long-term effectiveness of cbt for anxiety disorders in an adult outpatient clinic sample: a follow-up study cognitive behavioral therapy in anxiety disorders: current state of the evidence treating the trauma of rape: cognitivebehavioral therapy for ptsd cognitive-behavioral therapy for ocd mental health strategies to combat the psychological impact of coronavirus disease 2019 (covid-19) beyond paranoia and panic hypnosis and relaxation therapies a hypnotherapy intervention for the treatment of anxiety in patients with cancer receiving palliative care use of hypnotherapy in anxiety management in the terminally ill: a preliminary study the clinical use of hypnosis in cognitive behavior therapy: a practitioner's casebook gamification. using game-design elements in non-gaming contexts a virtual reality exposure therapy application for iraq war military personnel with post traumatic stress disorder: from training to toy to treatment cognitive processing therapy for veterans with military-related posttraumatic stress disorder virtual reality and cognitivebehavioral therapy for driving anxiety and aggression in veterans: a pilot study social support and mental health in community samples effects of social support and personal coping resources on depressive symptoms: different for various chronic diseases? social network mediation of anxiety behavior change techniques in top-ranked mobile apps for physical activity popular science. a panic attack can mimic the symptoms of covid-19. here's what to do about it e-health internationalization requirements for audit purposes coverage of health information by different sources in communities: implication for covid-19 epidemic response deep key: cord-287196-re4sosff authors: shahzad, fakhar; du, jianguo; khan, imran; fateh, adnan; shahbaz, muhammad; abbas, adnan; wattoo, muhammad umair title: perceived threat of covid-19 contagion and frontline paramedics’ agonistic behaviour: employing a stressor–strain–outcome perspective date: 2020-07-15 journal: int j environ res public health doi: 10.3390/ijerph17145102 sha: doc_id: 287196 cord_uid: re4sosff historically, infectious diseases have been the leading cause of human psychosomatic strain and death tolls. this research investigated the recent threat of covid-19 contagion, especially its impact among frontline paramedics treating patients with covid-19, and their perception of self-infection, which ultimately increases their agonistic behaviour. based on the stressor–strain–outcome paradigm, a research model was proposed and investigated using survey-based data through a structured questionnaire. the results found that the perceived threat of covid-19 contagion (emotional and cognitive threat) was positively correlated with physiological anxiety, depression, and emotional exhaustion, which led toward agonistic behaviour. further, perceived social support was a key moderator that negatively affected the relationships between agonistic behaviour and physiological anxiety, depression, and emotional exhaustion. these findings significantly contributed to the current literature concerning covid-19 and pandemic-related effects on human behaviour. this study also theorized the concept of human agonistic behaviour, which has key implications for future researchers. since december 2019, the global health system has been fighting with the growing number of cases of covid-19, a viral respiratory syndrome that first appeared in china and tentatively named 2019-ncov1 or sars-cov-2 [1] . the world health organization has assessed that the rate of covid-19 spread is expected to be very high and long-lasting [2] . as of 4 july 2020, the confirmed number of patients with covid-19 had reached 11.108 million, causing over 525,790 mortalities worldwide [3] . the rare history and lack of vaccines to control this novel virus may also cause a high level of panic. during a panic, healthcare personnel (in this study, paramedics, defined as "a person who is trained to give emergency medical treatment of sick persons or assist medical professionals") face not only physical challenges but also mental burdens, including psychological distress and fear [4, 5] . a higher sense of social support may be psychologically comforting [17] [18] [19] [20] . of course, social support can have a salutary effect on health. concurrently, the potential moderating effect of pss on human agonistic behaviour has received little interest from scholars. therefore, our study also examined the moderating role of pss on the association between selected strain factors (physiological anxiety, depression, and emotional exhaustion) and the agonistic behaviour of frontline paramedics. in this study context, understanding human agonistic behaviour will help to determine specific characteristics and potential mechanisms of human aggression and violence in a variety of contexts. agonistic behaviour is also known as agonism-survivalist animal behaviour, including defence, avoidance, and aggression. the term agonistic behaviour was first used to describe animal fighting behaviour [21] . it is an adaptive behaviour resulting from conflicts within the same species members [14] . while there is no commonly accepted definition of human agonism, it has usually been defined as the act of triggering psychological or physical harm to other persons or in the destruction of property [15] . moreover, it is further defined as 'the individual's aggressive verbal and physical tendencies and aggressive attitudes' [22] . agonistic behaviour can serve as a tool for distinct antisocial, constructive activities, and destructive acts. in both human and non-humans, agonistic behaviour is significantly influenced by the general principles of operant and classical conditioning learning and social modelling [17] . the biologist who favoured this concept recognised that behavioural stimuli and underlying feelings and approaches are frequently the same; and actual behaviour is dependent on other factors, especially distance to the stimulus [23] . moreover, the term 'agonistic' introduces that the differences between aggressive and agonistic behaviours have been blurred, and these two labels are often used interchangeably in the literature. in humans, aggression is repeatedly related to living conditions [17] . behaviour also depends on the level of awareness among group members when stressful events occur in a social environment because individuals are susceptible to behavioural signals [24] . one primary reaction during the pandemic is fear of contagion. humans react like other animals because they have a similar defence system against ecological threats [25] . negative emotions brought about by threats can be contagious, and fear makes threats more imminent [26, 27] . behaviour has, in part, a genetic basis, which generally is learned in a social context. several factors can cause positive and negative behavioural change. previous literature discussed the change in agonistic behaviour of animals species rather than the human species. this study thus empirically investigated agonistic behaviour in humans and assessed the effect of the perceived threat of covid-19 on agonistic behaviour by employing the sso model. this study will make a significant contribution to the existing theory of agonistic behaviour by elucidating how to measure human psychological cognition and behaviour. our framework is based on the sso model because we examined the influence of the perceived threat of covid-19 (a stressor) on agonistic behaviour [28] . this model divulges how stressors become prominent in individuals' lives, indicating that the stressor source has a direct influence on the strain, which later contributes to outcome variables. stressors are environmental stimuli that individuals experience and transmit stress. strain and outcomes are an individual's personal emotional, and behavioural responses to stressors [13] . summing up, the sso model considers that strain is the result of sensing stressors and the antecedent of the outcome variable. in the past, sso models have been used to comprehend stress in the workplace and behavioural change as an outcome variable [29] [30] [31] [32] . however, in the context of measuring agonistic behaviour among humans, the implementation of the sso model has not been sufficiently investigated. with the rapid rise in covid-19 cases, the severe threat to medical staff is imminent, which increases their physiological and psychosomatic strain [33] . in addition, the availability of equipment and pandemic control preparedness may have a moral effect on medical personnel [34] . however, the threat of getting sick from covid-19 persists, which also puts stress on paramedical personnel. this stress further affects the psychosomatic state of frontline paramedics and increases their agonistic behaviour. recent studies have also confirmed that the perceived fear of covid-19 contagion affects individuals' psychological distress [12, 34, 35] . since outcome factors interact with psychological responses and perceived stressors, the current research model included three valuable and practical individual strains. the first is physiological anxiety-"a level and nature of anxiety, including physiological worry/oversensitivity, social concerns and concentration" [36] . the second is depression-"a mental illness with physiological and psychological consequences, including sluggishness, diminished interest and pleasure, and disturbances in sleep and appetite" [37] . the third is emotional exhaustion-"the extent to which employees feel drained and overwhelmed by their work" [31] . in this study, agonistic behaviour-"adaptive acts which arise out of conflicts between two members of the same species"-was our dependent variable [15] . in prior literature, it was mostly used interchangeably with aggressive behaviour. few scholars have discussed human agonistic behaviour, particularly in the field of marketing and customers' buying behaviour [15, 17] . however, there is no empirical evidence concerning the impact of the perceived threat of covid-19 or any other pandemic-related fears from the perspective of the sso model. this motivated the authors to investigate the possible consequences of human agonistic behaviour. the sso model can be an effective way because it emphasises the positive effect of the environmental stimulus on the internal and external behaviour of frontline paramedics treating patients with covid-19. moreover, the sequential process of the sso model has been used to test the theoretical avowals made in this study, which includes how perceived threat of covid-19 affect the agonistic behaviour of frontline paramedics by creating physiological anxiety, depression, and emotional exhaustion. in this section, we will discuss how threats and risks may be perceived and responded to by people during a pandemic and its aftermath; specifically, fear causes individuals to change their behaviour. intense fear produces the greatest behavioural changes when people experience physical and psychosomatic disorders such as anxiety, depression, and emotional exhaustion [38] [39] [40] ; whereas intense fear can lead to aggressive and defensive responses [26] . therefore, we adapted the previous brief illness perception questionnaire (bipq) [41] to determine the level of perceived threat among frontline paramedics treating patients with covid-19. the concept of illness perception is related to how a person perceives the illness as well as the cognitive structuring of the status of being ill. the model recommends that situational stimuli can produce cognitive and emotional representations of health threats or illness [41] . in other terms, illness perception is the cognitive and emotional representations of patients' viewpoints about the disease [42] . this cognitive and emotional model also includes beliefs about the treatment and control of the situation. the emotional and cognitive interpretation and evaluation about the perception of illness are the determinants of their behavioural reactions, which is shaped by individuals' experiences, knowledge levels, and mental strain [43] . therefore, per prior directions [43] , we divided and validated the scale into two parts based on the emotional and cognitive perception of the threat of illness from covid-19. first, emotional threat is a psychological disorder characterised by uncontrollable and irrational fears, extreme hostility, or persistent anxiety. it identifies the illness consequences and concern that affect individuals' emotions and create anxiety and depression, making them angry, scared, and exhausted [41, 44, 45] . however, it is not the amount of emotions but rather the interpretation of emotional states that is essential for determining an individual's degree of psychological disorder [46] . they confirmed a relationship between the level of distress intolerance, anxiety, and bulimic behaviour in a non-clinical setting [46] . second, cognitive threat refers to the identification of an illness threat from a particular disease, understanding its expected effects, and lacking personal control over the situation [44] . it may also contribute to the creation of anxiety disorders and psychological distress, which ultimately leads to behavioural change [41, 43, 47] . fear of illness is inextricably linked with depression and anxiety [48] . per chinese scholars, a parallel epidemic of depression, anxiety, and emotional exhaustion is triggered by the covid-19 pandemic [4, 49] . in addition, recent studies posited that the pandemic had provoked widespread psychological issues, such as fear, anxiety, and depression, among countries with a high prevalence of viral infections [50, 51] . similarly, we assumed that perceived emotional and cognitive threat concerning covid-19 would create anxiety, depression, and emotional exhaustion among the paramedics treating patients with covid-19, which would ultimately lead to their agonistic behaviour (i.e., outcome). thus, we hypothesised the following: h1a: perceived emotional threat will be positively related to physiological anxiety. h1b: perceived emotional threat will be positively related to depression. h1c: perceived emotional threat will be positively related to emotional exhaustion. h2a: perceived cognitive threat will be positively related to physiological anxiety. h2b: perceived cognitive threat will be positively related to depression. h2c: perceived cognitive threat will be positively related to emotional exhaustion. anxiety disorders are often caused by stressful life events [13] . anxiety is defined as "an emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure" [52] . anxiety is also the cause and effect of many psychosomatic diseases and plays a role in the development of emotional psychosis [16] . prior literature described the possible role of stress and fear of sickness in the causation of submissive behaviour owing to anxiety [11, 53, 54] . how long the novel coronavirus will persist and how it will continue to influence the psychological well-being of healthcare staff is unknown. this psychological influence may lead to adverse behavioural change [55] . thus, we posited that physiological anxiety will increase extensively if the pandemic persists, which ultimately will increase frontline paramedics' agonistic behaviour. thus, we also proposed the following hypothesis: h3: physiological anxiety will be positively related to agonistic behaviour. depression refers to a 'psychological state of low mood and aversion to activity that can affect a person's thoughts, behaviour, motivation, feelings, and sense of well-being' [56] . the maladaptive actions in behavioural theories have underlined the occurrence of depression. cognitive behavioural therapy assumes that the root cause of depression is negative thinking patterns, which then lead to negative behavioural patterns [57] . people with depression have extremely negative views about themselves and the world. it is believed that long-lasting emotional stress is the pathogenic factor leading to the development of individual depression that leads to behavioural disorders [16, 58] . generally, during the early stages of a pandemic, people have little information about treatment and mortality, which exacerbates people's fear of infection, leading toward behavioural consequences [59] . consistently, depression rates are higher during the covid-19 pandemic as compared to before [6] . like anxiety, we posited that depression would increase the agonistic behaviours of frontline paramedics: h4: depression will be positively related to agonistic behaviour. emotional exhaustion is a stress-related social issue that may affect individuals' working behaviour [60] . it describes 'feelings of being emotionally overextended' [61] . consequences of emotional exhaustion can lead to behavioural disorders, a preference for remaining at home, and poor work performance [61, 62] . some studies have investigated the causes or consequences of employees' emotional exhaustion in work-related environments [31, [62] [63] [64] [65] . moreover, one study [63] concluded that greater levels of perceived pandemic threat could be used to anticipate increased levels of emotional exhaustion, leading to increased agonistic behaviour. given that the increased threat of the covid-19 pandemic predicts increased emotional exhaustion, it is reasonable to suggest that increased emotional exhaustion will contribute to exacerbated agonistic behaviour among frontline paramedics treating patients with covid-19. like anxiety and depression, we hypothesised the following: h5: emotional exhaustion will be positively related to agonistic behaviour. social support is defined as "social interactions or relationships that provide practical assistance to individuals or embedding individuals into a social system that is considered to provide love, care, or attachment to a valuable social group" [24] . simply, social support refers to all kinds of support that individuals obtain from others. social support is divided into actually received support and perceived support. although the received social support includes the assistance already provided, pss is a faith that these assisting behaviours will occur when needed in the future [66] . increased social support is coupled with better psychological outcomes, and pss (rather than actual social support) seems to indicate healthier psychological behaviours during times of stress [26] . moreover, pss was identified in the sars outbreak and organisational behaviour literature as adversely associated with burnout [67] . therefore, pss was selected as the focus of this research. various aspects of sociocultural background influence the degree and speed of behavioural change. social norms influence employees' behaviours, what they think about others' actions, and what they agree or disagree with at the workplace [68] . in addition, many studies have confirmed the relationship between decreased adolescent social support and increased aggression [69] [70] [71] [72] [73] . moreover, greater levels of perceived pandemic threat predict resulted in increased levels of psychological strain, whereas greater social support predicts a decreased effect of psychological strain on behaviour disorders [63] . increased pss also protects individuals with high levels of victimisation from increased health disorders such as depression, anxiety, emotional exhaustion [19, 69] . the moderating role of pss using the stress-buffering model was also a significant contributor to depressive symptoms among chinese nurses [20] . nonetheless, few studies have explored the impact of pss on the relationship between covid-19-related stress and psychological well-being [74, 75] . consequently, we posited that pss would buffer or moderate the relationship between strain (physiological anxiety, depression, emotional exhaustion) and outcome (agonistic behaviour). specifically, we hypothesised the following: h6a: pss will moderate the positive association between physiological anxiety and agonistic behaviour; i.e., a rise in pss will decrease the relationship strength between physiological anxiety and agonistic behaviour. h6b: pss will moderate the positive association between depression and agonistic behaviour; i.e., a rise in pss will decrease the relationship strength between depression and agonistic behaviour. h6c: pss will moderate the positive association between emotional exhaustion and agonistic behaviour; i.e., a rise in pss will decrease the relationship strength between emotional exhaustion and agonistic behaviour. the proposed model of this study is shown in figure 1 . the threat of covid-19 initially started after the first case was reported in china. regardless of common health issues, developing countries are still in the initial phases of tackling this uncertain situation. the covid-19 pandemic was first verified to have arrived in pakistan in february 2020 [76] and grew to 69,496 confirmed cases by 31 may 2020 [77] . paramedics, working in isolation wards, fever clinics, intensive care units and other related departments with an increased workload and risk of infection. in this study, the targeted population encompassed paramedics treating patients with covid-19 in pakistan who completed a survey. we adapted the survey items (see appendix a) for all constructs from prior literature and refined them to fit the context of this research before final data collection. however, in the preliminary analysis, an item from pss (item number 6) was excluded owing to low factor loadings and to authenticate the results [78] . moreover, to confirm the content validity of the proposed survey, a team composed of one professor and four scholars were requested to verify the wording and face validity of the survey questionnaire. the approved questionnaire was then distributed for data collection. in this study, the brief illness perception questionnaire (bipq) was adapted [41] to measure the perceived threat of covid-19 (0 to 10 scale) among frontline paramedics treating patients during the current pandemic. the initial eight-item questionnaire was divided into two categories as per prior directions [43] : perceived emotional threat and perceived cognitive threat. a sample item for the perceived emotional threat was, "how much does your threat of illness from covid-19 affect you emotionally"? a sample item for the perceived cognitive threat was, "how well do you feel you understand covid-19"? physiological anxiety was measured using 11 items (7-point likert scale) [36] , which were obtained from an earlier measure [53] . a sample item was "i cannot concentrate on a task or job without irrelevant thoughts intruding". the threat of covid-19 initially started after the first case was reported in china. regardless of common health issues, developing countries are still in the initial phases of tackling this uncertain situation. the covid-19 pandemic was first verified to have arrived in pakistan in february 2020 [76] and grew to 69,496 confirmed cases by 31 may 2020 [77] . paramedics, working in isolation wards, fever clinics, intensive care units and other related departments with an increased workload and risk of infection. in this study, the targeted population encompassed paramedics treating patients with covid-19 in pakistan who completed a survey. we adapted the survey items (see appendix a) for all constructs from prior literature and refined them to fit the context of this research before final data collection. however, in the preliminary analysis, an item from pss (item number 6) was excluded owing to low factor loadings and to authenticate the results [78] . moreover, to confirm the content validity of the proposed survey, a team composed of one professor and four scholars were requested to verify the wording and face validity of the survey questionnaire. the approved questionnaire was then distributed for data collection. in this study, the brief illness perception questionnaire (bipq) was adapted [41] to measure the perceived threat of covid-19 (0 to 10 scale) among frontline paramedics treating patients during the current pandemic. the initial eight-item questionnaire was divided into two categories as per prior directions [43] : perceived emotional threat and perceived cognitive threat. a sample item for the perceived emotional threat was, "how much does your threat of illness from covid-19 affect you emotionally"? a sample item for the perceived cognitive threat was, "how well do you feel you understand covid-19"? physiological anxiety was measured using 11 items (7-point likert scale) [36] , which were obtained from an earlier measure [53] . a sample item was "i cannot concentrate on a task or job without irrelevant thoughts intruding". depression was measured using 19 items (7-point likert scale) adapted from an earlier study [79] . a sample item was, "how often was this happen during the past 10 days; you were bothered by things that usually do not bother you? emotional exhaustion was measured using 12 items (7-point likert scale) adapted from an earlier study [31] , which were obtained from an earlier measure [80] . a sample item was, "it is hard for me to relax after dealing with covid-19 patients". perceived social support was assessed using 8-items (7-point likert scale) adapted from an earlier study [81] . a sample item was, "how much do you feel that your family pays extra attention to you during a current pandemic"? an aggression scale was adapted from an earlier study [22] as an objective gauge to assess individuals' agonistic behaviour. we critically analysed several aggression scales; however, we found regoeczi's aggression scale to be the most relevant to our definition of agonistic behaviour. a 5-items scale (7-point likert) was administered to participants. a sample item was, "how often did you feel you were too aggressive toward other people during the past 10 days"? consistent with the focus of this study, data were gathered through a structured questionnaire only from paramedical personnel treating patients with covid-19 in pakistan. in the punjab province of pakistan, there are two separate layers of professionals that support core medical personnel in their healthcare services, namely "paramedics" and "allied health professionals". paramedics are registered with punjab medical faculty (pmf), and allied health professionals are registered with the higher education commission (hec) [82] . in this study, we have collected the data only from the frontline paramedics working in punjab, pakistan particularly dealing with covid-19 patients. for this, we contacted the head of several quarantine centres and hospitals treating patients with covid-19 around punjab province, pakistan. they were informed of the study purpose. all possible questions were answered to their satisfaction, but no official data were collected to assure the privacy of the respondents and the organisations. after getting verbal permission from the concerned authority, we started our data collection process. data collection followed the computer-assisted web interview method-a data-gathering technique in which participants complete questionnaires through an online survey link without the guidance of the interviewer [83] . the expected circulation of the survey was around 1500 using snowball sampling. a total of 372 responses were recorded between 3 march 2020 and 17 may 2020. twenty-seven responses were omitted from final analyses because they were deemed unreliable [84] . moreover, the same size exceeding 200 meant it was reasonable to employ structural equation modelling (sem) [85] . considering the length of the survey (66 questions), utilising sem analyses was rational. moreover, we evaluated the sample adequacy on the advice of [86] , based on cohen's power theory. a post-hoc was applied for all exogenous indicators (significance level was set at 0.05, the effect size was 0.15, and the sample size was 345) to verify the statistical intensity of the study sample using g*power 3.1.9 (heinrich-heine-universität, düsseldorf, germany) [87] . the results of the post-hoc test revealed that the statistical power was 0.9, much higher than the 0.8 thresholds [88] . therefore, the final sample of 345 respondents was analysed by implementing the partial least square sem technique in smart-pls v3.2.9 (smart-pls gmbh, bönningstedt, germany). for our purposes, this was more suitable than covariance-based sem [89, 90] . table 1 outlines participants' characteristics (e.g., sex, age, and work experience): 38.6% were men, and 61.4% were women; 18.3% were aged ≤ 29 years old, 39.4% were aged 30 to 39 years, 40.6% were aged 40 to 49 years, and 1.7% were aged ≥ 50 years; and 20.9% had one to three years of work experience, 25.2% had four to six years of work experience, 26.1% had seven to nine years of work experience, and 27.8% had ≥ 10 years of work experience. [78] . to verify the convergent validity of each item, smart-pls v3.2.9 software was used to conduct a confirmatory factor analysis. table 2 shows the reliability and convergent validity of this study. in addition, cronbach's alpha of all factors ranged from 0.934 to 0.974, which was higher than the threshold value. concerning convergent validity, this study examined the similarity between operationalisation and theory. the composite reliability (cr) was 0.947 to 0.976, and the average variance extracted (ave) was 0.684 to 0.861. the suggested values for cronbach's alpha and cr should be greater than 0.7, and ave should be greater than 0.5; thus, the instrument was efficient and reliable [78, 91] and the data could be used for further structural analysis. to distinguish the extent of empirical variance among the constructs, discriminant validity evaluation has become a widely accepted assumption to analyse the relationship between potential factors [89] . in this study, we used three methods to evaluate discriminant validity. first, by associating the correlation of the factors with the square root of the ave. second, the survey items were checked through the cross-loading criterion to recognise the relevance. third, discriminant validity was measured by the application of heterotrait-monotrait ration (htmt) [89, 92, 93] . as described in table 3 , the correlation between constructs and the square root of ave was linked to quantify the discriminant validity of the instrument. the diagonal values in table 3 suggest that the square root of ave is higher than the correlation coefficients between all variables, a good indication of discriminant validity [93] . prior studies suggested cross-loadings criteria to assess discriminant validity [91, 94] . accordingly, the loading of each item should be higher than its subsequent construct, and the item loadings are also regarded as a threshold. the calculation results of item loadings and cross-loadings (see table 4 ) show that the loadings of each item are higher than the cross-loadings of other subsequent construct items. this shows that it has sufficient discriminant validity by satisfying the cross-loading criteria. finally, the htmt ratio criterion was established to illustrate the insensitivity of fornell and larcker's criterion and cross-loading criterion. the ratio of htmt was close to 1, indicating the lack of discriminant validity [91] . htmt is an estimate of factor correlation (or instead, the upper bound). to make a clear distinction between the two factors, htmt should be less than 1 [92, 95] . therefore, we employed the htmt ratio; the value in table 5 shows that the highest value is 0.75, which is lower than the above threshold, indicating sufficient discriminant validity. after examining reliability and validity, we measured the causal relationship between the factors with smart-pls v3.2.9 software [89, 95] . figure 2 shows the value of the path coefficient. the bootstrap technique was used to measure the significance of the structural model (2000 iterations of resampling). the expressive power of the research model is represented by the illustrative variation of its results (i.e., r 2 ). the r 2 (r-square) value of ab was 0.399, indicating that these selected variables represented 39.9% of the variation. moreover, the r 2 of physiological anxiety was 0.182, indicating that the mutation rate owing to perceived emotional threat (pet) and perceived cognitive threat (pct) was 18.2%. in addition, the r 2 of depression was 0.157 and the r 2 of emotional exhaustion was 0.177, indicating the active participation of perceived threat. after examining reliability and validity, we measured the causal relationship between the factors with smart-pls v3.2.9 software [89, 95] . figure 2 shows the value of the path coefficient. the bootstrap technique was used to measure the significance of the structural model (2000 iterations of resampling). the expressive power of the research model is represented by the illustrative variation of its results (i.e., r 2 ). the r 2 (r-square) value of ab was 0.399, indicating that these selected variables represented 39.9% of the variation. moreover, the r 2 of physiological anxiety was 0.182, indicating that the mutation rate owing to perceived emotional threat (pet) and perceived cognitive threat (pct) was 18.2%. in addition, the r 2 of depression was 0.157 and the r 2 of emotional exhaustion was 0.177, indicating the active participation of perceived threat. the sem results in figure 2 show that all exogenous factors are positively associated with endogenous factors. the p-value confirms the level of significance of the relationship between the proposed relations per the criterion [96, 97] . meanwhile, the value of standardized root mean square residual (srmr) is 0.042, and the value of normed fit index (nfi) is 0.891, showing the good fitness of the model. in figure 2 , the sem analysis results verify the path analysis coefficient between pet and physiological anxiety is (β = 0.267, p < 0.001). pet had a significant positive effect on physiological anxiety, and the beta correlation coefficient between pet and depression was significant (β = 0.221, p < 0.001). the findings further indicated that pet and emotional exhaustion were significantly positively correlated (β = 0.243, p < 0.001). based on these statistical findings, h1a, h1b, and h1c were supported. the sem results in figure 2 show that all exogenous factors are positively associated with endogenous factors. the p-value confirms the level of significance of the relationship between the proposed relations per the criterion [96, 97] . meanwhile, the value of standardized root mean square residual (srmr) is 0.042, and the value of normed fit index (nfi) is 0.891, showing the good fitness of the model. in figure 2 , the sem analysis results verify the path analysis coefficient between pet and physiological anxiety is (β = 0.267, p < 0.001). pet had a significant positive effect on physiological anxiety, and the beta correlation coefficient between pet and depression was significant (β = 0.221, p < 0.001). the findings further indicated that pet and emotional exhaustion were significantly positively correlated (β = 0.243, p < 0.001). based on these statistical findings, h1a, h1b, and h1c were supported. the beta coefficient of pct was significant (β = 0.194, p < 0.01), implying that it positively impacted physiological anxiety; therefore, h2a was supported. pct was positively correlated with depression and emotional exhaustion. pct and depression were also significantly positively correlated (β = 0.209, p < 0.01), as were pct and emotional exhaustion (β = 0.212, p < 0.001). therefore, h2b and h2c were supported. physiological anxiety also had a considerable effect on ab (figure 2 ; β = 0.234, p < 0.001). the coefficient values of depression and ab (β = 0.223, p < 0.001) and emotional exhaustion and ab (β = 0.232, p < 0.001) indicated that the selected strain factors (physiological anxiety, depression, and emotional exhaustion) had a substantial positive effect on the ab. therefore, h3, h4, and h5 are were supported. figure 2 shows the interaction value of the beta coefficient of pss on the association between physiological anxiety and ab (β = −0.242, p < 0.001), the coefficient value of pss on the association between depression and ab is (β = −0.238, p < 0.001), and the coefficient value of pss on the relationship between emotional exhaustion and ab (β = −0.221, p < 0.001). pss significantly and negatively influenced the relationships between physiological anxiety, depression, and emotional exhaustion with ab ( figure 3) . consequently, h6a, h6b, and h6c were supported. figure 3 also illustrates the moderating effect of pss on the relationship between physiological anxiety, depression, and emotional exhaustion with ab. in sum, per the present analyses, the proposed theoretical model was acceptable. h2b and h2c were supported. physiological anxiety also had a considerable effect on ab (figure 2 ; β = 0.234, p < 0.001). the coefficient values of depression and ab (β = 0.223, p < 0.001) and emotional exhaustion and ab (β = 0.232, p < 0.001) indicated that the selected strain factors (physiological anxiety, depression, and emotional exhaustion) had a substantial positive effect on the ab. therefore, h3, h4, and h5 are were supported. figure 2 shows the interaction value of the beta coefficient of pss on the association between physiological anxiety and ab (β = −0.242, p < 0.001), the coefficient value of pss on the association between depression and ab is (β = −0.238, p < 0.001), and the coefficient value of pss on the relationship between emotional exhaustion and ab (β = −0.221, p < 0.001). pss significantly and negatively influenced the relationships between physiological anxiety, depression, and emotional exhaustion with ab ( figure 3) . consequently, h6a, h6b, and h6c were supported. figure 3 also illustrates the moderating effect of pss on the relationship between physiological anxiety, depression, and emotional exhaustion with ab. in sum, per the present analyses, the proposed theoretical model was acceptable. the common method bias (cmb) possibly exposes the efficacy of this study. the survey notes informed participants that there were no right or wrong answers and that their replies would remain anonymous and confidential. moreover, harman's single factor test is usually used to test for the existence of cmb [98, 99] . we used spss v26 (ibm spss inc., chicago, il, usa) software to perform harman's single factor test. the first factor accounted for 40.9% of the variation. in social science literature, a value below 50% is the threshold of the cmb [98, 100, 101] . concurrently, the inner variance inflation factor (vif) was also used to evaluate the cmb problem. according to kock (2015) , inner-vif should be less than 3.3. we discovered that the value varied between 1.09 to 2.01; thus, cmb was not a problem in this study. the values of outer-vif were used for multicollinearity assessment of the survey items. the literature shows that if the vif value of a study is lower than 10, multicollinearity may not be a problem [102] [103] [104] . the highest value of vif was 5.93; thus, there was no severe multicollinearity problem. in sum, the proposed model did not have cmb or multicollinearity problems, indicating that the structural model measured significant differences between the constructs. the global understanding of disease transmission and management has improved during the several pandemics in history. however, covid-19 has limited global health authorities' abilities. as previous studies disclosed, working directly with patients will increase individuals' fear of getting sick and uncertainty about pandemic contagion [63, 105] , which we called perceived threat of covid-19 in this study. therefore, we investigated the impact of perceived covid-19 threat in forecasting greater levels of physiological anxiety, depression, and emotional exhaustion among frontline paramedics, which may boost their agonistic behaviour. another objective was to examine the moderating influence of pss in reducing the adverse consequences of physiological anxiety, depression, and emotional exhaustion on agonistic behaviour owing to the perceived threat of covid-19. the bipq [41] was used to measure the perceived threat of covid-19, which was divided into two constructs: perceived emotional threat and perceived cognitive threat. sem was applied to the data to test the research model under the podium of the sso framework. the results revealed that frontline paramedics in the isolation wards did not think that they were exempt from the peril, which was associated with increased psychological distress. moreover, paramedics worried about the inadequacy of protective measures and vigilance taken by the health department. paramedics' perception of risk contributed to their psychological morbidity and irregular behaviour. based on the empirical results, we postulated that an increased perceived threat of covid-19 would increase the level of paramedics' physiological anxiety and depression, which would ultimately increase their agonistic behaviour. a causal link between the perceived threat of covid-19 and psychological distress was found. after working in isolation for a considerable period, paramedics reported emotional exhaustion. treating patients with covid-19 had become routine, and they were inured to being around death almost every day. however, they also experienced substantial stress owing to the fear of getting ill during the pandemic. the cognitive and emotional threat from covid-19 was positively associated with increased emotional exhaustion at work, which was associated with paramedics' behavioural change. moreover, the results showed that pss reduced the effect of anxiety, depression, and emotional exhaustion on agonistic behaviour. pss is helpful as friends or family members provide social support and express empathy. with the increase in the number of cases of covid-19 infection around the globe, frontline paramedics are required to wear protective masks, protective clothing, and treat many patients with covid-19, which may cause added stress. however, pss can help reduce this stress by reducing the perception of the threat of stressful events and the physiological response and inappropriate behaviour that can result from stress. these results are also supported by prior studies [75, 106] . positive social feedback should thus be provided to frontline paramedics in times of uncertainty to offset potential agonistic behaviour. first, this research offers a more account of the theory of agonistic behaviour from the field of animal biological sciences to human behavioural science. the authors integrated the sso model with the theory of agonistic behaviour to examine the effects of the perceived threat of covid-19 on human agonistic behaviour. this empirical investigation elucidated human behaviour research. second, by using the sso model, this study tested several theoretical-based relationships between the perceived threat of covid-19 and human agonistic behaviour. most of the recent studies concerning covid-19 discussed the consequences and adverse effect on patients' health, daily life, economy, and education [4, 55, [107] [108] [109] [110] ; however, this study mainly concentrated on the perceived threat of covid-19 among frontline paramedics, and how it influenced their psychological strain and increased their agonistic behaviour. therefore, the authors hope that this model can be further extended and used as an ideal platform for future work in a similar context. third, this study further divided the bipq into two major parts-emotional and cognitive threats-and empirically tested it during the current pandemic situation. this significantly contributes to validating the existing scales and can be used in future research. this study also provides some useful insights for practice. first, the findings significantly highlighted the risk of infection that frontline paramedics face, which may cause several mental health problems such as anxiety and depression. health organisations should implement full security measures to protect this at-risk population to mitigate the threat of covid-19. second, the results emphasised the need for healthcare managers to understand the magnitude and sources of psychosocial stress faced by frontline paramedics. providing adequate protection and facilities, communicating effectively, creating transparent guidelines, and implementing appropriate feedback mechanisms for healthcare personnel are essential to reduce the strain in the current pandemic situation. third, this study highlights the significant role of pss in reducing the effect of psychological strain on agonistic behaviour. concerning stress management, it is also essential to strengthen social support in the workplace. for frontline paramedics with severe psychological strain, it is necessary to identify high-risk groups early, and provide counselling, social support, and stress management to mitigate negative behavioural change. some limitations need to be addressed while discussing the outcomes of the current study. first, a cross-sectional design was employed, and the agonistic behaviour of paramedics was measured during the current pandemic. future scholars should employ a multimethod or longitudinal design by comparing the results obtained during and after the covid-19 pandemic. second, this study did not examine sex and age differences. the level of threat may not be the same between female and male paramedics. similarly, those in different age groups will respond to strain differently and may display agonistic behaviour in diverse ways. therefore, multigroup analyses should examine any possible sex or age differences. third, the strain factors discussed in this study are not limited to these particular factors; future researchers could extend the model using several other factors such as scepticism, sadism, and poor sleep quality, which may impact human agonistic behaviour. organisational and government support can also be used as a moderating factor in addition to pss. finally, future researcher should continuously validate the scale used in the current study. our study concludes that the effect of perceived covid-19 threat on predicting greater levels of physiological anxiety, depression, and emotional exhaustion among frontline healthcare paramedics may contribute to their agonistic behaviour. moreover, we have concluded the moderating role of pss in decreasing the adverse effect of physiological anxiety, depression, and emotional exhaustion on agonistic behaviour due to the perceived threat of covid-19. our study provides understanding about human agonistic behaviour will help to identify precise characteristics and probable mechanisms of human aggression and violence in several contexts, which will contribute to the implementation of conflict management practices in the workplace. "you felt sad?" "you felt that people disliked you?" "it was hard to get started doing things?" "you felt life was not worth living?" emotional exhaustion "it is hard for me to relax after dealing with covid-19 patients." "if others speak to me, i will sometimes give an errant reply." "i mostly feel annoyed while dealing with covid-19 patients." "i sometimes act aggressively, although i do not want to do so. " "i feel irritable after dealing with covid-19 patients for hours." "i feel emotionally drained sometimes." "i feel used up at the end of my work." "i feel fatigued when i get up in the morning and being confronted with news of covid-19 patients." "i feel burned out from dealing with covid-19 patients. " "i feel frustrated after work." "i fell, i am working with covid-19 patients for too long." "dealing with covid-19 patients puts too much stress on me." perceived social support "how much do you feel that adults care about you?" "how much do you feel that your employer care about you?" "how much do you feel that your parents care about you?" "how much do you feel that your friends care about you?" "how much do you feel that people in your family understand you?" "how much do you feel that you want to leave home?" (deleted) "how much do you feel that you and your family have fun together during a current pandemic?" "how much do you feel that your family pays extra attention to you during a current pandemic?" agonistic behaviour "how often did you feel, you were too aggressive toward other people during the past 10 days?" "how often did you feel, you influence other people too much to get what you want during the past 10 days?" "how often did you feel, not at all aggressive-aggressive during the past 10 days?" "how often did you feel, you like people to be afraid of you during the past 10 days?" "how often did you feel, you try to get into a position of authority during the past 10 days?" behavioral and emotional disorders in children during the covid-19 epidemic who director-general's opening remarks at the media briefing on covid-19 covid-19 dashboard by the center for systems science and engineering (csse) factors associated with mental health outcomes among health care workers exposed to coronavirus disease the impact of covid-19 epidemic declaration on psychological consequences: a study on active weibo users psychological status of surgical staff during the covid-19 outbreak covid-19 and italy: what next? the mental health of medical workers in wuhan, china dealing with the 2019 novel coronavirus association between depression and enterovirus infection generalized anxiety disorder, depressive symptoms and sleep quality during covid-19 outbreak in china: a web-based cross-sectional survey stress, definitions, mechanisms, and effects outlined: lessons from anxiety adaptation of the fear of covid-19 scale: its association with psychological distress and life satisfaction in turkey stress and health: psychological, behavioral, and biological determinants hostility and aggression agonistic behavior agonistic behavior: a model, experimental studies, and perspectives agonistic behaviour in marketing: an extended abstract moderating role of perceived social support between perceived parenting styles and relational aggression in adolescents perceived social support moderates the link between attachment anxiety and health outcomes the moderating role of perceived social support on the relationship between physical functional impairment and depressive symptoms among chinese nursing home elderly in hong kong the causes of fighting in mice and rats the impact of density: the importance of nonlinearity and selection on flight and fight responses on farm monitoring of pig welfare behavior: overview the ecology of human fear: survival optimization and the nervous system using social and behavioural science to support covid-19 pandemic response affective signals of threat increase perceived proximity a preliminary test of a stress-strain-outcome model for reconceptualizing the burnout phenomenon differential challenge stressor-hindrance stressor relationships with job attitudes, turnover intentions, turnover, and withdrawal behavior: a meta-analysis the consequences of technostress for end users in organizations: conceptual development and validation when social networking turns to social overload: explaining the stress, emotional exhaustion, and quitting behavior from social network sites' users factors associated with compassion satisfaction, burnout, and secondary traumatic stress among chinese nurses in tertiary hospitals: a cross-sectional study the effect of covid-19 and subsequent social distancing on travel behavior preparedness of frontline doctors in jordan healthcare facilities to covid-19 outbreak the effects of covid-19 and its psychological impact on people, agricultural extension in south asia neutralizing job stressors: political skill as an antidote to the dysfunctional consequences of role conflict fast facts: depression a meta-analysis of fear appeals: implications for effective public health campaigns anxiety inventory (bai) behavioral health epidemic of covid-19 in china and associated psychological problems the brief illness perception questionnaire the role of illness perceptions in patients with medical conditions factor structure and psychometric properties of the brief illness perception questionnaire in turkish cancer patients the illness perception questionnaire: a new method for assessing the cognitive representation of illness bin laden: effect of state emotion on perceived threat is mediated by emotion towards the threat agent perception of threat from emotions and its role in poor emotional expression within eating pathology stress, anxiety, depression, and physical illness in college students when stress is mental illness: a study of anxiety and depression in employees who use occupational stress counselling schemes patients with mental health disorders in the covid-19 epidemic structure of anxiety associated with the covid-19 pandemic in the russian-speaking sample: results from on-line survey a nationwide survey of psychological distress among chinese people in the covid-19 epidemic: implications and policy recommendations encyclopedia of psychology self-report assessment of anxiety: somatic, cognitive, and behavioral modalities college students' academic stress and its relation to their anxiety, time management, and leisure satisfaction impact of sars-cov-2 and its reverberation in global higher education and mental health empirical evidence for definitions of episode, remission, recovery, relapse and recurrence in depression: a systematic review convergences among psychoanalytic and cognitive-behavioral theories of depression sleep loss and behaviour for the prefrontal cortex and psychiatric disorder timely mental health care for the 2019 novel coronavirus outbreak is urgently needed emotional exhaustion as a predictor of job performance and voluntary turnover the relationship of emotional exhaustion to work attitudes, job performance, and organizational citizenship behaviors the role of psychosocial working conditions on burnout and its core component emotional exhaustion-a systematic review emotional exhaustion and state anger in nurses who worked during the sars outbreak: the role of perceived threat and organizational support explaining emotional labor's relationships with emotional exhaustion and life satisfaction: moderating role of perceived autonomy emotional exhaustion and sleep-related worry as serial mediators between sleep disturbance and depressive symptoms in student nurses: a longitudinal analysis received and perceived social support in times of stress: a test of the social support deterioration deterrence model severe acute respiratory syndrome (sars) in hongkong in 2003: stress and psychological impact among frontline healthcare workers social influence: compliance and conformity negative cognitive style and perceived social support mediate the relationship between aggression and nssi in hospitalized adolescents perceived family and social support: impact on children suicidal adolescents' social support from family and peers: gender-specific associations with psychopathology community violence victimization and aggressive behavior: the moderating effects of coping and social support peer influence in adolescence: public-health implications for covid-19 the effect of covid-19 stress on sexual compulsivity symptom: the mediating role of perceived social support 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 pakistan detects first coronavirus cases, links to iran outbreak gop see the realtime pakistan and worldwide covid-19 situation partial least squares structural equation modeling (pls-sem): an emerging tool in business research adolescent first sex and subsequent mental health the measurement of experienced burnout immigrant generation, assimilation, and adolescent psychological well-being factors influencing the success of e-government frequently asked questions about using mechanical turk for research principles and practice of structural equation modeling pls-sem) power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences statistical power analysis for behavioural sciences how to specify, estimate, and validate higher-order constructs in pls-sem structural equation models with unobservable variables and measurement error: algebra and statistics a new criterion for assessing discriminant validity in variance-based structural equation modeling evaluating structural equation models with unobservable variables and measurement error enhancing the flow experience of consumers in china through interpersonal interaction in social commerce using pls path modeling in new technology research: updated guidelines a step-by-step guide to get more out of your bootstrap results advanced issues in partial least squares structural equation modeling common method biases in behavioral research: a critical review of the literature and recommended remedies sources of method bias in social science research and recommendations on how to control it a comparison of three models to explain shop-bot use on the web common method bias in pls-sem: a full collinearity assessment approach power, and interpretation of multiple regression analysis on the misconception of multicollinearity in detection of moderating effects: multicollinearity is not always detrimental multivariate data analysis with readings sars control and psychological effects of quarantine effects of doctors' empathy abilities on the cellular immunity of patients with advanced prostate cancer treated by orchiectomy: the mediating role of patients' stigma, self-efficacy, and anxiety a panel analysis on preventing and controlling efficiency of covid-19 pandemic effects of covid-19 pandemic in daily life pandemics show us what government is for the economic impact of the coronavirus 2019 (covid-2019): implications for the mining industry this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we acknowledge the anonymous reviewers and editor for their feedback and all paramedics who participated in this study. the authors declare no conflict of interest. perceived emotional threat "how much does covid-19 affect your life?" "how much do you feel symptoms covid-19 contagion?" "how concerned are you about covid-19 contagion?" "how much does your threat of illness from covid-19 affect you emotionally? (e.g., does it make you angry, scared, upset or depressed)" perceived cognitive threat "how long do you think covid-19 will continue?" "how much control do you feel over covid-19 contagion?" "how much do you think that current treatment is helpful from the recovery of covid-19 contagion?" "how well do you feel you understand covid-19?" physiological anxiety "i picture some future misfortune." "i cannot get some thoughts out of my mind." "i abide on mistakes that i have made." "i think about possible misfortunes to my loved ones." "i cannot concentrate on a task or job without irrelevant thoughts intruding." "i keep trying to avoid uncomfortable thoughts." "i cannot get some pictures or images out of my mind." "i imagine myself appearing foolish with a person whose opinion of me is important." "i am concerned that others might not think well of me." "i have to be careful not to let my real feelings show." "i have an uneasy feeling." depression how often was this happen during the past 10 days: "you were bothered by things that usually do not bother you?" "you did not feel like eating, and your passion was poor?" "you felt that you could not shake the blues, even with help from family and friends?" "you felt that you were just as good as other people?" "you had trouble keeping your mind on what you were doing?" "you felt depressed?" "you felt that you were too tired to do things?" "you felt hopeful about the future?" "you thought your life had been a failure?" "you felt fearful?" "you were happy?" "you talked less than usual?" "you felt lonely?" "people were unfriendly to you?" "you enjoyed life?" key: cord-318363-1mv5j4w2 authors: zvolensky, michael j.; garey, lorra; rogers, andrew h.; schmidt, norman b.; vujanovic, anka a.; storch, eric a.; buckner, julia d.; paulus, daniel j.; alfano, candice; smits, jasper a.j.; o'cleirigh, conall title: psychological, addictive, and health behavior implications of the covid-19 pandemic date: 2020-08-27 journal: behav res ther doi: 10.1016/j.brat.2020.103715 sha: doc_id: 318363 cord_uid: 1mv5j4w2 • the public health impact of covid-19 on psychological symptoms and disorders, addiction, and health behavior is substantial and ongoing. • an integrative covid-19 stress-based model could be used to guide research focused on the stress-related burden of the pandemic. • this work could provide a theoretical and empirical knowledge base for future pandemics. around some of the most clinically important psychological disorders, addictive behaviors, and health behaviors for well-being. in the first section, we describe the covid-19 implications for mental health focusing on (a) anxiety/stress and mood disturbance, (b) obsessive compulsive symptoms and disorders, and (c) posttraumatic stress. such mental health problems, although certainly not exhaustive of the scope of psychological disorders impacted by covid-19, are some of the most common mental health issues in the general population and are frequently comorbid with chronic illness. in the second section, we focus on addictive behaviors, including (d) tobacco (combustible and electronic), (e) alcohol use and misuse, and (e) cannabis. these forms of drug use represent the most prevalent types of substance use and are frequently associated with chronic illness and premature death. in the third section, we spotlight health behavior and chronic illness by discussing the role of (f) sleep health and behavior, (g) chronic illness using the example of hiv/aids as an illustrative model, and (h) physical activity. health behaviors represent vital targets for the mitigation of covid-related disease and may play a key role in psychological adjustment and recovery. in the final section, we highlight sociocultural factors (e.g., race/ethnicity, economic adversity), developmental considerations, and the role of individual difference factors for psychological, addictive, and health behavior and chronic illness. we conclude by offering an integrative covid-19 stress-based model that could be used to guide research focused on the stress-related burden of the pandemic. fear is an adaptive defense mechanism that is fundamental for survival and involves several psychological and biological processes of preparation for a response to potentially j o u r n a l p r e -p r o o f threatening events. covid-19 represents a true threat, with many unknowns. if you are infected, there is a chance you could die, regardless of your current age, sex, or health status. as such, fear is a natural and adaptive response to this pandemic. on the other hand, every year tens of thousands die from influenza as well as many other preventable or unexpected causes. this raises the key question regarding the degree to which we should be anxious and fearful of . how much anxiety is reasonable? since even basic knowledge about covid-19 is undeveloped, it will be difficult to clearly discriminate between normal, adaptive fear responses and less adaptive responses. that said, such an overarching true threat and the concomitant stressors such as social isolation, economic uncertainty and so forth could in fact recalibrate what is considered a normal level of anxiety in the general population. research has demonstrated that trait levels of anxiety have increased in the us in recent decades, though the cause of such increases is unknown (twenge, 2000) . the covid-19 pandemic is likely to contribute to these basic levels of trait anxiety, thus creating a "new normal" level of anxiety. if we consider the likely general increase in anxiety and stress in the context of diathesisstress conceptualizations of mental illness, we expect that such a salient and broad reaching stressor to increase the incidence of pathological anxiety. anxiety conditions are already highly prevalent (bandelow & michaelis, 2015) , and we may see an increased incidence of anxiety psychopathology if the pandemic serves to push vulnerable individuals toward the expression of maladaptive levels of anxiety. moreover, those with preexisting conditions are likely to have their symptoms intensify. one could further speculate that forms of pathological anxiety will increase. first responders and hospital personnel, particularly in affected areas are already showing troubling signs of stress and psychopathology (joob & wiwanitkit, 2020) . it is highly j o u r n a l p r e -p r o o f likely that we will see increased rates of generalized anxiety and posttraumatic stress related to the pandemic and its sequelae. beyond the somewhat vague notion of covid-19 acting as a stressor to increase both normal and pathological anxiety, it is interesting to consider the specific mechanisms that play a role in this process. there are several well-established parameters that relate to the genesis and maintenance of anxiety that seem highly relevant to the current situation. these processes include perceptions relating to predictability/certainty and controllability of threat (barlow, 2004) . coming across a shark while swimming is quite different from viewing the same shark in an aquarium since a potential threat in the wild is far less predictable or controllable than one in an enclosure. historically, epidemics and pandemics were considered divine punishments that were essentially uncontrollable. although medical understanding of pathogens has advanced, globalization now facilitates the spread of pathological agents, which diminishes the degree to which we can control them. similarly, naturally occurring mutations and adaptation of viruses ensure that novel pathogens like covid-19 will emerge and spread. these conditions leave us in a state of uncertainty, except that we can be certain that covid-19 and other infectious agents will persist. thus, covid-19 affects many of the core anxiety generating mechanisms since it leads to a sense of diminished predictability and controllability along with increased uncertainty relating to a true threat. ultimately, the covid-19 pandemic creates an ideal environment for the onset, maintenance, and exacerbation of anxiety symptoms and syndromes. the dsm-5 posttraumatic stress disorder (ptsd) criterion a (american psychiatric association [apa] , 2013, p.271) defines trauma as "exposure to actual or threatened death." individuals who are closer to that exposure --providing healthcare to those infected, witnessing j o u r n a l p r e -p r o o f the deleterious and perhaps deadly effects of the virus on patients or loved ones, enduring losses of patients, family, or friends --might experience the crisis as potentially traumatic. people on the frontlines of the pandemic, including healthcare personnel, first responders, grocery store clerks, and other essential workers, encounter the threat of possible exposure to the virus regularly and on an ongoing basis. similarly, incarcerated populations and those who might feel compelled, financially or otherwise, to work in close quarters without adequate personal protective equipment (e.g., factory workers) may be exposed to the covid-19 virus for extended periods without perceived or actual recourse and suffer negative mental health repercussions as a result. covid-19 survivors, particularly those who might have struggled through various medical procedures and prolonged hospitalizations, may emerge with unique or shared constellations of mental health reactions from risk to resilience. additional high-risk groups include healthcare professionals or first responders who may have experienced significant moral injuries (jinkerson, 2016; joannou, besemann, & kriellaars, 2017; williamson, stevelink, & greenberg, 2018 ) as a result of making unfathomable decisions on the job (e.g., providing admission or ventilator access to one patient at the sacrifice of another). yet, in addition to considering direct impacts of the novel covid-19 virus on our population, it is imperative to understand the secondary potentially traumatic effects of the pandemic on individuals and communities. the combination of prolonged stress, close quarters, and self-isolation guidelines has increased risk of domestic violence, child abuse, and substance use (abramson, 2020; national institute on drug abuse, 2020; santhanam, 2020; taub, 2020) . indeed, physical and sexual violence may escalate without the regular societal checks provided by employers, schools, and loved ones. furthermore, such violence may stem from and/or intensify more unbridled substance use (carter et al., 2020) emerging from a context where j o u r n a l p r e -p r o o f uncertainty and unpredictability are high, practical stressors (e.g., unemployment, financial stress, food insecurity) may be difficult to problem-solve, and social supports may be distant. furthermore, in this pandemic, issues of grief and loss are inevitably interwoven with those of potential trauma. spiritual and emotional grief processes to honor and emotionally mourn the losses of loved ones may be interrupted by this pandemic, potentially exacerbating or prolonging grief, traumatic bereavement, or ptsd reactions. to understand the effects of covid-19 on the mental health of those who experience it as potentially traumatic, we need to recognize first that the impacts of trauma may not be fully determined nor completely recognizable until after the traumatic stressor has concluded. the covid-19 crisis is going to have a long, yet undetermined course, and thus our ongoing reactions to it are dynamic but indicative of peri-traumatic rather than post-traumatic coping (bell, boden, horwood, & mulder, 2017; lapid pickman, greene, & gelkopf, 2017) . based upon decades of research, we can expect the majority of the population, regardless of level of proximity to or interaction with covid-19, to demonstrate resilience and to recover psychologically in the aftermath of the pandemic (alisic et al., 2014; kilpatrick et al., 2013) . a relative minority, the proportions of which are unknown, may emerge from the crisis with clinical or subclinical ptsd or with exacerbation in pre-existing ptsd symptoms and related mental health conditions (e.g., depression, substance use disorder). women are at heightened risk of ptsd following potentially traumatic events (gaffey et al., 2019; rattel et al., 2019) and racial/ethnic minority populations may be especially impacted due to socioeconomic inequities and health-related disparities with regard to financial security and access to healthcare and treatment (asnaani & hall-clark, 2017; cross et al., 2018; sibrava et al., 2019) . the intersections of trauma and the covid-19 pandemic are complex. many constellations of interweaving risk and protective factors, learning histories, and life circumstances can affect how trauma histories and potentially traumatic experiences during the covid-19 crisis can affect individual journeys of recovery. for example, more unbalanced, negative individual interpretations of the covid-19 crisis and related changes in beliefs about oneself, others, or the world may have lasting deleterious effects (e.g., "i am damaged"; "people cannot be trusted"; "the world is dangerous and unsafe"; beierl, böllinghaus, clark, glucksman, & ehlers, 2019; bernardi & jobson, 2019; köhler, goebel, & pedersen, 2019; losavio, dillon, & resick, 2017; scher, suvak, & resick, 2017) . similarly, avoidance of thoughts or emotions related to the covid-19 crisis may increase the risk of developing ptsd symptoms and/or exacerbating or maintaining pre-existing trauma-related symptoms (e.g., orcutt, reffi, & ellis, 2020) . additional risk factors for the development or exacerbation of ptsd symptoms include a prior history of trauma or mental health disturbances, depressed or anxious mood, significant concurrent life stressors (e.g., financial problems, job loss, relationship stress), low social connectedness or support, sleep disturbance, substance use, and emotional numbing or detachment (colvonen, straus, acheson, & gehrman, 2019; cusack et al., 2019; germain, mckeon, & campbell, 2017; hancock & bryant, 2018; shalev et al., 2019; steenkamp et al., 2017; vujanovic & back, 2019) . navigating the covid-19 crisis requires a tolerance of uncertainty that is challenging for all, but especially trauma survivors who may have endured, sometimes over months or years (e.g., combat, childhood abuse), unfathomable circumstances that were, by definition, unpredictable and uncontrollable (e.g., raines, oglesby, walton, true, & franklin, 2019; vujanovic & zegel, 2020) . undoubtedly, social connection and a sense of community and collectivism, hope, psychological awareness, and healthy coping will j o u r n a l p r e -p r o o f differentiate risk versus resilience trajectories during and after this crisis (bernardi & jobson, 2019; long & gallagher, 2018; thompson, fiorillo, rothbaum, ressler, & michopoulos, 2018) . learning who suffers long-term negative effects of the covid-19 pandemic, why, and under what circumstances will help us to understand how to intervene most effectively to psychologically support trauma survivors in the aftermath of this and future societal crises. indeed, reactions of trauma survivors to the covid-19 crisis are also likely to be as diverse as the traumas and individuals themselves with the possibility of emergent themes. theoretically, individuals with histories of being directly impacted by natural disasters, people recovering from severe medical conditions, and those with histories of imprisonment or captivity may feel especially emotionally reactive to the large community-level impact, the social distancing and quarantining aspects of weathering covid-19, and the continual perceived health threat inherent to the pandemic. individuals with interpersonal trauma histories may experience a solidification or exacerbation of maladaptive beliefs relevant to trust, safety, or power. others may feel increased social detachment or engage in increased harmful, self-injurious, or suicidal behaviors, particularly those with mood or substance use disorders. for some trauma survivors, following social distancing and self-quarantine guidelines may lead to less frequent exposure to trauma-related reminders in the outside world and/or a lower perceived interpersonal threat due to social-isolation, but increased trauma-related avoidance during the covid-19 crisis in turn may exacerbate ptsd symptoms in the long-term. a high-risk subset may emerge who are slow or reluctant to heed public health guidelines due to a reaction against efforts to control, an increased risk-taking propensity, all-or-none thinking, or helplessness resulting from a history punctuated by traumatic, uncontrollable events. this may lead to incessant attempts, by some, to attain perceived control via closely monitoring news, stockpiling food, or supplies, and maintaining constant vigilance. for those affected by trauma prior to and/or during the covid-19 crisis, the current, chronically stressful global atmosphere where uncertainty reigns may feel especially overwhelming. for others, this crisis may foster growth and resilience as they endure and overcome a crisis of epic and unimaginable proportions. obsessive-compulsive disorder (ocd) is a common (1-2% incidence; (nestadt, bienvenu, cai, samuels, & eaton, 1998; ruscio, stein, chiu, & kessler, 2010) , disabling mental health condition characterized by presence of obsessions and/or compulsions (american psychiatric association, 2013; markarian et al., 2010) . symptoms present in a heterogeneous fashion across a number of dimensions, including contamination/cleaning, taboo obsessions (i.e., sexual, aggressive content), symmetry/repeating/ordering, and checking (mckay et al., 2006) . childhood onset occurs in over 50% of cases and symptoms run a chronic course without adequate intervention (pinto, mancebo, eisen, pagano, & rasmussen, 2006) . clinical presentation is further characterized by frequent comorbidity (stein et al., 2019) and variable degrees of insight (hamblin, park, wu, & storch, 2017) . the covid-19 pandemic is likely to have a number of effects on those with ocd, as well as those at risk. this includes the potential for symptom exacerbation and increased incidence of ocd cases, as well as having implications for assessment and treatment post-covid-19. patients with ocd commonly present with contamination obsessions and associated cleaning compulsions (mataix-cols, do rosario-campos, & leckman, 2005; pinto et al., 2006) . some individuals with contamination related ocd have reported that their symptoms have worsened in light of public health recommendations for increased cleaning behaviors (e.g., washing, wearing masks) and other safety behaviors (e.g., social distancing, wearing masks), j o u r n a l p r e -p r o o f which may be difficult for some patients to maintain within recommended guidelines. covid-19 has become a feared outcome for many patients with contamination-related ocd similar to other what has been observed with other infectious diseases (e.g., hiv). outside of contamination-focused symptomology, other obsessive-compulsive symptoms may be affected such as harm obsessions whereby someone fears that they may have unintentionally spread covid-19. stress has an established relationship with worsened obsessive-compulsive symptoms (adams et al., 2018; brander, perez-vigil, larsson, & mataix-cols, 2016) , and availability of coping strategies is taxed for many; this may further impact ocd symptom presentation as well as comorbidity patterns. although systematic data have not been presented, clinical accounts support symptom worsening for some affected individuals while, on balance, many others have not experienced negative symptomatic change. beyond worsening of symptoms in those with ocd, there is the possibility that there will be increased cases in the near future. this may involve those with subclinical symptoms or other risk factors experiencing onset or worsening of symptoms. the behavioral cycle of ocd/anxiety highlights the role of negative reinforcement in which rituals/avoidance are reinforced by distress reduction and creating a cognitive sense of control (i.e., not getting covid-19 is due to compulsions; rector, wilde, & richter, 2017) . in this scenario, a person with or at risk for ocd may engage in rituals/safety behaviors in response to obsessional distress which in turn reduces anxiety and is perceived as reducing the risk. reduction in distress may motivate further safety behaviors which, for some at risk, could begin to exceed recommended guidelines. while ordinary levels of risk have risen requiring increased hygiene, it remains to be seen what happens when risk levels decline. that is, do cleaning behaviors likewise decline or remain at elevated states thereby impacting diagnosis rates? assessment approaches should continue to capture j o u r n a l p r e -p r o o f obsessive-compulsive symptoms that are impairing, distressing and excessive relative to current risk levels and not count symptoms that reflect behaviors consistent with accepted public health standards. there are also treatment implications. the gold standard psychological treatment for adult and childhood ocd is cognitive behavioral therapy with exposure and response prevention (erp; mcguire et al., 2015; olatunji, davis, powers, & smits, 2013) . this treatment involves gradual exposure to triggers that evoke obsessive-compulsive symptoms while refraining from completing rituals or other avoidance behaviors. a core element to this treatment is that exposure to triggers involves exposure to 'ordinary' levels of risk. covid-19 understandably has shaken what is perceived as ordinary; fortunately, adept therapists have shifted their practice to utilize exposures that reflect this new normal such as relying on imaginal exposures or exposures targeting rituals in excess of public health agency recommendations. at the same time, some clinicians have negative attitudes towards exposure (meyer, farrell, kemp, blakey, & deacon, 2014) which is related to reduced practice of this core therapeutic technique (farrell, deacon, kemp, dixon, & sy, 2013) . it will be critical to provide guidelines established by expert erp clinicians for how providers integrate realistic covid-19 concerns into their ongoing practice, as well as that in the future. a concerning possibility is that erp treatment post-covid-19 is diluted by virtue of therapists not practicing exposures to the actual level of risk. cigarette smoking remains the leading cause of preventable death and disability globally. smoking may confer worse covid-19 outcomes given extensive evidence for the negative impact of smoking on lung health and respiratory function (tonnesen, marott, nordestgaard, j o u r n a l p r e -p r o o f bojesen, & lange, 2019). indeed, emerging evidence has identified smoking as a possible risk factor for adverse covid-19 prognosis and disease progression (patanavanich & glantz, 2020; vardavas & nikitara, 2020) . in the largest study of covid-19 patients, 16.9% of severely affected patience were current smokers relative to 11.8% of non-severe patients (guan et al., 2020 ). an inverse pattern emerged with non-smokers such that a greater proportion of nonsevere patients identified as a non-smoker relative to severe patients. moreover, 25.5% of covid-19 patients who either needed mechanical ventilation, were admitted to an intensive care unit, or died from complications related to the disease were current smokers relative to 11.8% of those not experiencing these outcomes. similar disparities in covid-19 severity across smoking status have been observed in other samples (w. j. zhang et al., 2020) . thus, these data, albeit preliminary and limited by sample size, indicate that smoking is a risk factor for covid-19 progression (w. . taking a biological perspective to understand why smokers are more susceptible to severe covid-19 symptoms, recent research has proposed that smoking and covid-19 susceptibility and symptom severity may be related to an upregulation of the angiotensin-converting enzyme-2 (ace2) receptor (brake et al., 2020) . ace2, a membrane-bound aminopeptidase that plays a vital role in cardiovascular and immune systems, is highly expressed in the heart and the lungs (turner, hiscox, & hooper, 2004; wang, luo, chen, chen, & li, 2020) . studies have established that ace2 is a receptor for the covid-19 virus (j. , and greater ace2 gene expression has been observed in smokers compared to non-smokers (brake et al., 2020; cai, 2020; emami, javanmardi, pirbonyeh, & akbari, 2020; tian et al., 2020; wan, shang, graham, baric, & li, 2020; zhao et al., 2020; . the upregulation in ace2 creates an environment that allows greater potential for covid-19 to j o u r n a l p r e -p r o o f infect human cells among smokers through more opportunity to bind to this receptor (olds & kabbani, 2020; zuluaga, montoya-giraldo, & buendia, 2020) . in part, this biological mechanism may help explain observed sex differences in covid-19. specifically, covid-19 symptom severity and mortality rates in china indicate worse outcomes for men than for women, where 52.1% of men and 2.7% of women are current smokers (parascandola & xiao, 2019; sun et al., 2020) . it is possible that the elevated smoking rates among men in china, and therefore greater upregulation in ace2, contributed to significant gender difference in covid-19 incidence and severity (j. . in addition to combustible cigarette smoking, there also is growing concern for the impact of electronic cigarette (e-cigarette) use on covid-19 infection and disease progression (lewis, 2020) . although it is believed that the worldwide distribution and adoption of ecigarettes has the potential to increase population-level vulnerability to respiratory infecting diseases (olds & kabbani, 2020) , such as covid-19, no studies have assessed e-cigarette use among covid-19 patients (farsalinos, barbouni, & niaura, 2020) . given evidence for the impact of various e-cigarette formulations on lung health and functioning (viswam, trotter, burge, & walters, 2018) as well as the fact that most e-cigarette users are former or current combustible cigarette users (mirbolouk et al., 2018) , it is possible that product use will critically impact the course of covid-19 among users. additionally, similar to combustible cigarette use, it has been theorized that e-cigarette use may engage an upregulation in ace2 that parallels that of combustible cigarette use and increases the likelihood of covid-19 infection (brake et al., 2020) . further research on these products and their influence on covid-19 outcomes is urgently needed. a final point to consider is the effect that the covid-19 pandemic itself has on smoking. one of the leading reasons for smoking is stress management (baker, piper, mccarthy, majeskie, & fiore, 2004; garey et al., in press) . the psychological effect of the current global environment, characterized by feelings of fear, uncertainty, isolation, and stress (mertens, gerritsen, salemink, & engelhard, 2020) , coupled with limited availability of adaptive coping tools due to regulations and consequences of covid-19 (i.e., social distancing, financial hardship) likely increases the risk for smoking onset, increased intensity, and relapse (patwardhan, 2020; stubbs et al., 2017) . smoking initiation and severity, in turn, increase susceptibility for covid-19 and worse disease-related outcomes. behavioral scientists must engage in targeted efforts to support current smokers and former smokers in achieving and maintaining cessation during this particularly challenging time. there are promising initial findings from smoking cessation programs implemented in smokers managing other infectious disease that may help guide some of these initiatives . as more is learned about covid-19, it is imperative that health care providers assess smoking (and e-cigarette) use status as well as relapse potential among former users and provide appropriate education and intervention to help mitigate the potential risk of this health behavior on disease infection and course. the (mis)use of alcohol is a leading risk factor for global disease burden and preventable death (degenhardt et al., 2018; organization, 2019) . alarmingly, alcohol use, high-risk drinking, alcohol use disorder (aud), and alcohol-related deaths were increasing before the covid-19 pandemic (grant et al., 2017; white, castle, hingson, & powell, 2020) . despite the widespread belief that moderate alcohol consumption may confer health benefits (diaz et al., 2002; j o u r n a l p r e -p r o o f et al., 2007) , more recent work suggests that any alcohol consumption is associated with health risks (griswold et al., 2018) . in fact, given the immunosuppressing effects of alcohol both generally and in the respiratory system specifically (molina, happel, zhang, kolls, & nelson, 2010; szabo & mandrekar, 2009) , it is germane to consider the role that alcohol consumption, whether chronic or in acute response to the ongoing crisis, may have on contraction of the covid-19 virus. in addition to the direct physiological impact of alcohol consumption on the body, the disinhibiting properties of alcohol (kumar et al., 2009; oscar-berman & marinković, 2007) may put individuals at risk for other risky/poor decisions (george, rogers, & duka, 2005) . for example, those under the influence of alcohol may be more likely to violate social distance protocols, exhibit poor hand washing procedures, or refuse/forget to wear a face covering in public, leading to potential exposure to and/or spreading of the virus. importantly, impulsivity has reciprocal relationships with alcohol such that consumption increases impulsive behaviors and individuals with greater trait impulsivity (mis)use alcohol to a greater extent (dick et al., 2010) . moreover, the effects of impulsivity on alcohol (mis)use can be amplified by other factors, such as stress, to confer greater risk for alcohol (mis)use (fox, bergquist, gu, & sinha, 2010) . it is well-documented that stress, both acute and chronic, is a trigger for alcohol (mis)use (becker, lopez, & doremus-fitzwater, 2011; blaine & sinha, 2017) . the covid-19 pandemic has brought about both acute (e.g., work displacement, limited availability of cleaning supplies) and chronic stress (e.g., financial difficulty, isolation) that likely will contribute to alcohol (mis)use for coping. it also is reasonable to expect that alcohol (mis)use will worsen during the crisis in response to the stress and uncertainty. for example, during the 2008-2009 economic recession, although there was a decrease in prevalence of alcohol use overall (i.e., increase in j o u r n a l p r e -p r o o f abstainers), there was an increase in prevalence of binge drinking (bor, basu, coutts, mckee, & stuckler, 2013) . this suggests that there may be a realignment/concentration of problematic drinking such that a greater segment of those who do consume alcohol may be doing so in a maladaptive or harmful way. although sales to restaurants and events have reduced markedly during the pandemic, sales of online and to-go alcohol have skyrocketed (nielsen, 2020) . given shelter in place orders and limits on socializing, it is possible that greater amounts of alcohol are being consumed at home/solitarily relative to social contexts. solitary drinking can, in some circumstances, lead to greater alcohol consumption than social drinking (kuendig & kuntsche, 2012) and is associated with greater alcohol-related consequences overall (christiansen, vik, & jarchow, 2002) . for many, the covid-19 pandemic has led to significant social isolation with in-person socializing virtually eliminated and many working from home (if at all). these conditions may also exacerbate a common reason for alcohol-related relapse: boredom (levy, 2008) . without other adaptive ways to manage stress, socialize, or simply occupy one's mind, it is possible that craving for alcohol may intensify. finally, there are important treatment implications for alcohol (mis)use during covid-19. individuals already report numerous barriers to seeking drug/alcohol treatment (mcgovern, xie, segal, siembab, & drake, 2006) . in the wake of the pandemic additional barriers may arise such as the perception that one's treatment is not a priority during a 'life or death' pandemic or not worth the risk of leaving one's home. alternatively, for those seeking treatment, there may simply not be local resources available or treatment facilities may have waitlists. although the use of telehealth services are growing in general (dorsey & topol, 2016) , there is more work to be done, with specific considerations for low-income individuals (e.g. recently unemployed) who j o u r n a l p r e -p r o o f may be reluctant to spend money on treatment, perceive treatment to be a luxury, or not have technological resources or a private location to engage in telehealth. affordable computer-based treatments without the need for a provider that focus on stress and alcohol use (paulus, gallagher, neighbors, & zvolensky, 2020) could be particularly pertinent during this pandemic. administration center for behavioral health statistics and quality, 2019) presumably due at least in part to legalization of recreational and/or medical marijuana at the state level (johnston, o'malley, miech, bachman, & schulenberg, 2015) . notably, cannabis users report using more cannabis during times of heightened distress following national disasters such as the september 11, 2001 terrorist attacks, a pattern that was especially prominent among individuals who experienced post-traumatic stress disorder and depression (vlahov et al., 2002) . it therefore follows that cannabis use and associated problems may increase during the covid-19 pandemic. cannabis use increases during times of distress to manage negative affect. in support of this contention, cannabis users report relaxation and tension relief as one of the most common reasons for use (copeland, swift, & rees, 2001; hathaway, 2003; reilly, didcott, swift, & hall, j o u r n a l p r e -p r o o f 1998). data from experimental studies support these self-reports. to illustrate, current cannabis users were randomly assigned to an anxiety-induction or non-anxious control condition and cannabis craving increased from before to during the task among participants in the anxiety condition, but not among those in the control condition (buckner, ecker, & vinci, 2013) . these data indicate that cannabis users were especially vulnerable to wanting to use cannabis during an anxiety-provoking situation, which has direct implications for the covid-19 pandemic characterized by heightened stress. notably, this effect was specific to cannabis craving and was not observed for craving for alcohol or cigarettes in this sample of cannabis users. coping motives are the most common reasons cited for wanting to use during laboratory-induced anxiety (buckner, zvolensky, ecker, & jeffries, 2016) . prospective data collected via ecological momentary assessment also confirm that anxiety is positively, significantly related to cannabis craving at the momentary level, and is related to greater subsequent craving (buckner, crosby, silgado, wonderlich, & schmidt, 2012) . further, although positive and negative affect were greater immediately prior to cannabis use compared to non-use episode, negative affect increased at a significant rate prior to cannabis use, and decreased at a significant rate following cannabis use; changes in positive affect were not significantly related to use (buckner et al., 2015) . further, the stress associated with the covid-19 pandemic may serve as trigger for lapse and/or relapse among individuals undergoing a cannabis quit attempt. in a qualitative interview following cannabis quit attempts, situations involving negative affect and exposure to others smoking cannabis were among the most difficult situations individuals reported in which to abstain (hughes, peters, callas, budney, & livingstone, 2008) . among cannabis users undoing a self-guided quit attempt, data from ecological momentary analysis indicated that although positive and negative affect were significantly higher during cannabis lapse episodes compared j o u r n a l p r e -p r o o f to non-use episodes, when negative and positive affect were analyzed simultaneously, negative affect, but not positive affect, remained significantly related to lapse (buckner, zvolensky, & ecker, 2013) . again, the most common reason for use cited during lapse episodes was to cope with negative affect. not only could covid-19 increase cannabis use, but cannabis use may exacerbate covid-19 symptoms given that smoking cannabis damages the lungs. respiratory toxins (including carcinogens) in cannabis smoke are similar to that of tobacco smoke but notably the smoking topography for cannabis leads to higher per-puff exposures to inhaled tar and gases (tashkin & roth, 2019) . further, respiratory symptoms such as chronic cough, sputum, and airway mucosal inflammation are also similar between cannabis smokers and tobacco smokers. the impact on respiratory functioning of cannabis smoke has led for the consideration of cannabis use as a pre-exiting condition that could increase the likelihood of more severe complications should one contract covid-19 (national institute on drug abuse, 2020). sleep is a fundamentally restorative process, but it is also highly responsive to stress (irwin, 2015) . during times of increased stress, sleep, quite paradoxically, serves both as a major line of defense and as a source of heightened vulnerability. these relationships derive from the fact that sleep and immunological functioning are reciprocally related: sleep promotes healthy immune responses and healthy immune responses (e.g., to infectious agents) promote deeper, more restorative sleep (opp, 2005) . precise mechanisms are of course complex, but several specific links are noteworthy. immune-signaling proteins called cytokines, such as tumor necrosis factor (tnf) and interleukin-1 (il-1) directly target infection and inflammation but are j o u r n a l p r e -p r o o f also known to promote sleepiness and non-rapid eye movement (nrem) sleep (jewett & krueger, 2012) . the hormone melatonin, which provides an endogenous marker of circadian phase peaks during the nocturnal sleep period but also has important immunomodulatory effects. conversely, the hypothalamus-pituitary-adrenal (hpa) axis and the sympathetic nervous system (sns), two primary stress response systems, are down-regulated during sleep, decreasing immune-regulating cortisol levels (besedovsky, lange, & born, 2012) . however, when sleep is inadequate or disrupted, alteration in these systems is readily observable. experimental sleep research provides overwhelming evidence for the detrimental effects of chronic sleep disruption on immune responses including increases in multiple inflammatory markers such as c-reactive protein, diminished immune response to vaccination, and enhanced susceptibility to bacteria and toxins (besedovsky et al., 2012) . rather than representing enhanced immunity, elevated levels of inflammation are associated with a range of health risks including cardio-pulmonary disease (libby, 2006) . sleep's inextricable role in human immunological functioning clearly place it at the forefront of critical behaviors during a pandemic. unfortunately, multiple aspects of the covid-19 pandemic threaten healthy sleep patterns which in turn endanger both physical and mental health. widespread uncertainty, 24-hour media coverage (including misinformation), fear for one's own health and the health of loved ones, and potential loss of employment/wages are but a few of the significant sources of stress present during these unprecedented times. heighted psychological and physiological arousal elicited by such stress falls in direct odds with a calm, quiescent state necessary for sleep onset and maintenance. further, common behaviors aimed at managing increased stress and anxiety such as smoking, alcohol consumption, and decreased physical activity can give rise to or worsen sleep disruption via known negative effects on sleep j o u r n a l p r e -p r o o f duration and quality (irish, kline, gunn, buysse, & hall, 2015) . moreover, sleep deprivation can amplify inflammatory responses (bollinger, bollinger, oster, & solbach, 2010) , increasing the risk for poor outcomes in covid-19 as unrestrained inflammation is implicated in the pathophysiology of the disease (gamaldo, shaikh, & mcarthur, 2012) . although predisposing (e.g., genetics) and precipitating (e.g., trauma) factors play a role, stress is considered a primary cause of insomnia (morin, rodrigue, & ivers, 2003 ) and among insomniacs, perceived inability to sleep often becomes a major source of stress in its own right. studies that have systematically examined incidence and severity of insomnia symptoms during a global pandemic are unavailable despite ubiquitous anecdotal reports and cautions from health professional regarding the immunosuppressive effects of poor sleep. however, in a recentlypublished study conducted between january 29 and february 3, 2020, c. zhang et al. (2020) surveyed medical staff responding to the covid-19 pandemic in china using the insomnia severity index (isi; morin, belleville, bélanger, & ivers, 2011) . more than a third of workers (36.1%) endorsed symptoms indicative of clinical insomnia and those with insomnia reported elevated levels of depression. insomnia is well-known to herald the onset of depression both acutely and years later even among those who have never been depressed (baglioni et al., 2011) . studies directed at uncovering precise mechanisms of affective risk during the covid-19 pandemic must therefore consider the presence and severity of insomnia symptoms. the covid-19 pandemic also has upended daily routines and associated 'cues' that serve to maintain regular sleep schedules. working from home, altered mealtimes, increased sedentary behavior, social distancing, and increased "screen time" are only some of the changes that hold potential to disrupt circadian rhythms that govern sleep-wake patterns. other factors such as social activities also can affect sleep-wake patterns. the human internal circadian clock j o u r n a l p r e -p r o o f runs slightly longer than 24 hours and therefore needs to be 'entrained' to the 24-hour day via internal and external cues (czeisler et al., 1999) . sunlight is the most potent exogenous cue that aligns our internal rhythm to the external environment, but quarantine measures and greater time spent indoors means that many individuals are receiving inadequate dosages of light exposure. although public health guidelines center on sufficient sleep duration (watson et al., 2015) , sleep timing is equally critical for overall health and well-being. misalignment of the sleep period with the body's 'biological night' is routinely linked with a host of serious risks, including anxiety, depression, suicide, cardiac events, and several forms of cancer (baron & reid, 2014) . healthcare workers who are working long hours and night shifts during the covid-19 pandemic are therefore a particularly high-risk group for circadian shifts and associated comorbidities. considering sleep's role in immunological function, this represents an area of priority for future research. the intersection of covid-19 with pre-existing chronic medical illness (e.g., cardiovascular disease, diabetes, hiv) raises additional challenges to the patient for managing multiple treatment cascades. these challenges are exacerbated by the poorer survival and disease course for patients with underlying medical conditions (emami et al., 2020) which in turn seems to be driving, in part, the alarming covid-19 racial disparity (laurencin & mcclinton, 2020) . the overlapping epidemic of covid-19 with hiv, for example, presents unique challenges for hiv access to care, hiv treatment engagement, and prevention. infection or if it exacerbates the likelihood of poor covid-19 outcomes. however, people living with hiv may have other comorbidities, such as cardiovascular disease and chronic lung disease, j o u r n a l p r e -p r o o f that increase the risk for a more severe course of covid-19 illness (guaraldi et al., 2011; guo et al., 2020) . there is also a concern that individuals who are immunocompromised, such as those with hiv, may be at greater risk for severe covid-19 symptoms (cdc, 2020a; duffau et al., 2018) . in the u.s., most people living with hiv (plwh) are tested, linked to hiv care, well engaged in antiretroviral treatment, and achieve hiv viral suppression thus ensuring their optimal health and protecting the public health by containing onward transmission (cdc, 2020b). however, structural and individual barriers to treatment and prevention create enduring inequalities and significantly increase the risk of infection, reduce access to, and engagement in, hiv care, and compromise participation in hiv biobehavioral prevention among particular risk groups. gay and bisexual men (particularly hispanic and african american men) are most impacted by hiv and account for nearly 70% of new hiv cases. hiv incidence rates in the u.s. are also significantly higher for those who are homeless or living in poverty (denning & dinenno, 2020) . with respect to individual barriers to care, plwh are disproportionally affected by traumatic life experiences, anxiety, depression, and substance use (brandt et al., 2017; nanni, caruso, mitchell, meggiolaro, & grassi, 2015; c. o'cleirigh, magidson, skeer, mayer, & safren, 2015) . each of these also have been associated with poorer engagement in hiv care, worse antiretroviral medication adherence, and poorer hiv disease course. their co-occurrence and interaction significantly increases both the risk for hiv infection (mimiaga et al., 2015) and poorer hiv disease management among those already infected (harkness et al., 2018; pantalone, valentine, woodward, & o'cleirigh, 2018) . these mental health barriers to full engagement in hiv care may well be exacerbated by increased levels of covid-19 specific anxieties and j o u r n a l p r e -p r o o f increases in general health-related anxieties. the requirements of social distancing also may contribute to feelings of isolation and loneliness which may in turn contribute to increased depression or depression-related withdrawal. both anxiety-related avoidance and depressive related withdrawal will likely have negative consequences for self-care generally and for hiv care specifically. these increases in distress will occur at a time when access to behavioral health services is already severely restricted. some plwh who become co-infected with covid-19 will already be struggling with hiv disease management (e.g., missed medical appointments, sub-optimal medication adherence) and may require additional supports to manage care and treatment at a time when many routine supports may not be available due social distancing and lack of routine medical services. protecting access to care and treatment among those already struggling with the complexities of the hiv care cascade who must now manage the additional burdens of the covid-19 illness is a robust clinical concern. here, we underline the importance of community (carrico et al., 2020) and health worker based approaches (operario, king, & gamarel, 2020) to hiv treatment and protecting access to care through innovative and virtual care models. many of those at risk for being lost to care during this covid-19 pandemic also may be vulnerable to perceived stigma (krier, bozich, pompa, & friedman, 2020; logie, 2020 ). many will have multiple stigmatized identities with respect to hiv status, covid-19 status, substance use, sexual or gender minority status, and others. keeping our community members and peers involved in our service delivery will help ensure our treatments are delivered in stigma-free contexts. empirical support for integrated treatment platforms that address mental health (ironson et al., 2013; safren, o'cleirigh, skeer, elsesser, & mayer, 2013) and substance use issues (mimiaga et al., 2019; safren et al., 2012) to protect engagement in hiv treatment and j o u r n a l p r e -p r o o f prevention (mayer et al., 2017; conall o'cleirigh et al., 2019) are available to guide these initiatives. in addition, protecting access and supporting engagement (virtual or otherwise), to mental health and substance use treatment will be critically important. these approaches may be particularly key for protecting access to hiv prevention services (i.e., hiv testing, access to preexposure prophylaxis [prep]) for those at risk for hiv. access to these services may be particularly important for those whose behavioral risk profiles and risk appraisals may be disturbed because of the impact of social distancing on usual patterns of substance use or sexual behavior. although much remains unknown about covid-19 and the mental health consequences of the pandemic, it is likely that regular physical activity offers protective effects. regular physical activity reduces risk of and helps manage conditions that appear to increase risk of adverse outcomes of covid-19 (e.g., obesity, cardiovascular disease, diabetes; lee et al., 2012) , and improves immune function (nieman & wentz, 2019) which likely positively affects the progression of covid-19. it also buffers the effect of stressors and (in part thereby) can prevent the onset of mental health conditions (harvey et al., 2018; jacquart et al., 2019) . further, diminished physical activity can disrupt sleep quality (buman & king, 2010; youngstedt & kline, 2006) , which increases susceptibility to infection and mental and physical illness (see sleep section). hence, establishing or maintaining a regular physical activity habit has the potential to mitigate the impact of the pandemic both at a personal and societal level. establishing and maintaining a regular physical activity habit has proven to be challenging. indeed, only 24% of adults meet the guidelines set forth by the department of health and human services (whitfield et al., 2019) . the covid-19 pandemic has impacted j o u r n a l p r e -p r o o f several factors, including a change in the daily routine and increased stress and anxiety, that can affect the intent of or ability to engage in behavior change. it is important to acknowledge the relationship between factors such as stress or changes in routine and physical activity participation can vary in strength or direction (i.e., negative or positive) depending on the individual and their context. for example, for some routine changes have created barriers for exercise participation, while for others changes to the daily structure have opened opportunities to engage in regular exercise. similarly, stress and anxiety at the "right" level can be motivating for some make exercise part of their daily routine, but when stress and anxiety become overwhelming, automated emotion action tendencies often cause people to move away from healthy (coping) behaviors such as exercise (otto et al., 2016) . importantly, such relationships may further vary within and across individuals depending on other individual difference variables (e.g., risk factors, protective factors, [mental] health diagnosis) and contextual factors (e.g., job loss, financial stress, isolation). research aimed at understanding the relationship between covid-19 and physical activity mostly likely will benefit from considering the importance of individual differences and the influence of contextual factors. comprehensive assessment batteries and statistical models that include the testing of these complex moderation effects are key. this perspective that acknowledges nuance in the relationship between covid-19 (pandemic) and physical activity also will aid efforts to develop or fine-tune intervention programs for physical activity uptake. the covid-19 pandemic, although still ongoing and presently under investigated from a behavioral health perspective, is apt to impart acute and potentially chronic exacerbations in psychological symptoms and disorders, addictive behavior, and health behavior and chronic j o u r n a l p r e -p r o o f illness. across various phenotypes overviewed in the current essay, previous scientific work and theoretical models predict covid-19, regardless of acquisition of the virus, has and will continue to have a strong negative psychological impact on negative mood states, various forms of substance use, and sleep, chronic illness, and physical activity. although many of these relations would be expected, theoretically, to be negative, select subgroups will certainly adaptively respond to covid-19 related stress (e.g., improve their physical fitness, improve self-care routines, quit/reduce maladaptive behaviors that place them at risk). in this final section of the paper, we discuss sociocultural considerations, developmental issues, and the role of individual difference factors for covid-19-related psychological, addictive, health behavior and chronic illness. we conclude by offering an integrative covid-19 model that could be used to guide research focused on the stress-related burden of the pandemic. certain subpopulations and contextual factors (e.g., loss of work) are likely to signify a vulnerability gradient for covid-19 in terms of mental health, addictive behavior, and health behavior. although there are numerous possible sociocultural factors that could be relevant, we highlight first responders and medical professionals, economic adversity, and racial/ethnic factors as three prototypical factors of public health importance. of all the sectors of the population, first responders and front-line healthcare professionals are arguably at the greatest risk for at least acute disruptions in anxiety, stress, and negative mood. first responders and healthcare professionals at the front line of the covid-19 pandemic have at their core mission to protect and preserve life (prati & pietrantoni, 2010) . these groups, although engaging in a diverse range of specific occupational activities (e.g., direct medical care, transport, public safety j o u r n a l p r e -p r o o f enforcement), share in common that they are among the first to respond to the covid-19 crisis and take primary responsibility for attending to covid-19 related health issues. first responders and healthcare professionals are undoubtedly experiencing emotionally challenging and unpredictable situations that can place their lives in danger. the acute emotional effects of managing covid-19 cases is likely to be amplified by heavy work schedules and reduced access to and isolation from social support systems (e.g., self-isolation after finishing a shift). it is likely that first responders and healthcare professionals working with covid-19 cases in hospitals will be exposed to potentially traumatic events, the greater-than-usual experience of life-threatening situations, working with emotional strain related to isolation of patients from their families (e.g., compassion stress in the form of offering emotional support to patients in a manner that family or caregiver of patients would typically offer), and exposure to the struggle to life and death. these experiences are apt to challenge the coping resources of even the most seasoned professionals, which can result in higher degrees of anxiety, stress, and depressed mood (lafauci schutt & marotta, 2011) . such elevated stress levels are likely to be related to changes in cognition and physical health, including emotional exhaustion, fatigue, sleep dysfunction, and problems with interpersonal relationships (kronenberg et al., 2008; lane, lating, lowry, & martino, 2010) . cognitive-based beliefs about personal safety and health can be altered and memories of potentially traumatic events engrained (setti & argentero, 2014) . collectively, the covid-19 related stress burden, as discussed in several sections of the current essay, will have a high likelihood of being related to increased risk of anxiety and depression for first responders and medical professionals working at the front line. moreover, consistent with past literature of these populations, the regulation of affect will be associated with addictive and health behavior to modulate such affect (e.g., physical activity, substance j o u r n a l p r e -p r o o f use). although some regulatory behavior will be adaptive (e.g., increasing sleep where possible to aid in recovery, engaging in regular physical exercise), others may be less adaptive (e.g., smoking to reduce stress) and promote the risk for other health problems (e.g., physical illness). economic adversity. economic hardship related to covid-19 is already evident at numerous levels of analysis, including job loss, reduced earnings, higher debt relative to assets ratio, inability to pay mortgage and bills, meeting governmental guidelines for poverty status, and worry about financials resources going forward due to the turbulent nature of the economy. past work has shown that economic hardship is related to behavioral health problems, including psychological disorders, addictive behavior, physical health problems, and interpersonal dysfunction in adults and children (k. j. conger et al., 2012; sareen, afifi, mcmillan, & asmundson, 2011) . for instance, economic adversity has been linked to reduced social competence and elevated physiological markers of stress (k. e. bolger, patterson, thompson, & kupersmidt, 1995; evans & english, 2002) . further, economic hardship is related to selfregulation capacity and the corresponding difficulty in dealing with additional responsibilities. for example, past work has found limited socioeconomic resources are related to harsher parenting behavior and greater substance use (r. d. conger & donnellan, 2007) . the negative effects may be particularly profound when economic hardship is severe or chronic (dearing, mccartney, & taylor, 2001; magnuson & duncan, 2002) . the totality of worsening economic conditions for individuals and families in the larger context of an uncertain economic future are apt to be related to elevations in anxiety, stress, and depression as well as other negative emotional states (e.g., anger, frustration, fatigue; newland, crnic, cox, & mills-koonce, 2013) . such emotional symptoms and problems are likely to be related to elevations in substance use and other maladaptive behavior (e.g., less supportive interpersonal behavior, less affection) and j o u r n a l p r e -p r o o f may exacerbate chronic health conditions. other work has found that these processes also disrupt social interconnections (scaramella, sohr-preston, callahan, & mirabile, 2008) . primary care givers who have children home from school, are unlikely to be able to work at their full capacity even with added flexibility in schedules. although certain occupations have decreased activity, many have not. therefore, it could be expected that for individuals with added responsibilities of educating their children at home occupational stress may be greater compared to those without such responsibilities. further, it is possible that the accumulation of occupational responsibilities that are not addressed for persons with additional educational responsibilities will accumulate and make it more challenging to recover when going back to 'normal,' resulting in a greater degree of occupational stress. grappling with lower socioeconomic states related to covid-19 will, for certain segments of the population, offer an additional psychological challenge. indeed, past work has repeatedly documented that lower socioeconomic status is related to adverse health outcomes for chronic illness and mortality rates (adler et al., 1994; adler, boyce, chesney, folkman, & syme, 1993) . moreover, harms faced by people who cannot afford not to work in dangerous settings can exacerbate the psychological and health risk associated with coid-19. further essential workers are more apt to be persons of color (handerson, mccullough, & treuhaft, 2020) . certain groups will be more likely to recover than others, which past work indicates is related to poorer health outcomes even at higher socioeconomic levels (kraus, borhani, & franti, 1980) . moreover, research has found that lower socioeconomic persons experience more chronic stress and negative life events (stansfeld, north, white, & marmot, 1995) . additionally, lower socioeconomic status is related to cognitive biases for threat (chen & matthews, 2001) , which engender greater degrees of interpersonal conflict and heightened negative emotional states j o u r n a l p r e -p r o o f (matthews et al., 2000; stansfeld, head, & marmot, 1997) . it would be expected that such negative emotional experiences will be related to maintained direct relations with poorer health behavior and health outcomes (mcewen & stellar, 1993) . in fact, research has consistently found that lower socioeconomic status is related to greater degrees of anxiety, stress, and depression when compared to those higher in socioeconomic status (mcleod & kessler, 1990) . this heightened stress reactivity may be at least in part attributable to having fewer resources. consequently, those struggling with a lower socioeconomic status due to covd-19 may be more contexts in which they must utilize their emotional resources and be less likely to be in a sociocultural context wherein such resources can be replenished (holahan, moos, holahan, & cronkite, 1999) . this perspective is in line with past work that has found that when persons are exposed to chronic stress, emotional resources are challenged, and there is a greater risk for future emotional distress (n. bolger & zuckerman, 1995; ensel & lin, 1991) . there is broad band evidence that significant health disparities exist for persons of racial/ethnic minority in the u.s. and beyond prior to covid-19 for psychological, addictive behavior, and health behavior as well as chronic illness. for example, african american/black individuals experience a disproportionate burden in disease morbidity, mortality, disability, and injury (mechanic, 2005; mensah, mokdad, ford, greenlund, & croft, 2005) . indeed, african american/black individuals remain significantly and consistently more at risk for early death than do similar non-latinx white individuals (williams, neighbors, & jackson, 2003; williams, yu, jackson, & anderson, 1997) ; overall early death rates of african american/black individuals are comparable to those observed among non-latinx whites in the u.s. decades ago (levine et al., 2016; williams & jackson, 2005) . differences in prevalence and rate of growth of chronic illness are not accounted for solely by j o u r n a l p r e -p r o o f exposure to lower income environments (franks, muennig, lubetkin, & jia, 2006) . indeed, social determinants of health (e.g., racism; krieger & sidney, 1996) , addictive behavior (e.g., tobacco use; sakuma et al., 2015) , and stress represent robust and consistent factors related to health inequalities among african american/black individuals and those from other underrepresented racial/ethnic groups. the covid-19 pandemic has appeared to strike racial and ethnic minority populations (e.g., african american/black) hard and with possible longerterm consequences. for example, less access to health care services for chronic illness, addictive behavior, and mental illness could exacerbate covid-19 related symptoms or promote a greater degree of stress-related burden associated with the pandemic (e.g., worry that loved ones, if infected, cannot access care). consequently, addictive behaviors (e.g., smoking, alcohol misuse) and health behaviors (e.g., disrupted sleep, emotional eating) may be used in the short-term to cope with such covid-19 related stress, increasing the longer-term risk for more severe negative emotional symptoms and health complaints (e.g., pain) and chronic health problems (e.g., obesity). additionally, situations characterized by mass fear and confusion, such as the current pandemic, also can elicit a human instinct to resolve the confusion and mitigate the fear by identifying a culprit for the introduction or spread of the disease (bard, verger, & hubert, 1997; bromet, 2011) . asian american persons are one group that has been singled out as responsible for the covid-19. the misdirection of fear and/or anger related to covid-19 toward a racial or ethnic group instead of the disease, however, can perpetuate fear and contribute to racism and stigma. several reports have already documented the rise in violent crimes and discrimination experienced by asian american persons related to covid-19 beliefs (e. liu, 2020) . covid-19 specific language, such as referring to covid-19 as 'the chinese virus,' has created a platform j o u r n a l p r e -p r o o f to propagate stigma and discrimination towards asian americans. it is likely that stigma and discrimination experienced by asian americans in response to covid-19 will increase emotional distress, coping-oriented addictive behavior, and may alter health behavior or exacerbate chronic illness. it would also be remiss to not call explicit attention to the fact that societies marked by greater economic and social inequality experience far more medical, psychological, and social pathology than do societies where such wealth inequalities are less pronounced (wilkinson & pickett, 2006 . further, such adverse effects occur across social classes, not merely among the most disadvantaged. yet, the adverse effects of economic (and thus social) inequality hurt everyone, although the poorest or most marginalized are affected the most (pickett, kelly, brunner, lobstein, & wilkinson, 2005; wilkinson & pickett, 2008) . there are far-reaching implications for psychological health, addictive behavior, and health behavior from a developmental perspective. for children, despite covid-19 appearing to have less severe symptoms and lower mortality rates than other age groups, are among the highest risk groups (sinha et al., 2020; zimmermann & curtis, 2020) . estimates suggests that there are over 1 billion children not in school (cluver et al., 2020) . the economic impact of covid-19 will likely be related to greater risk for children to be utilized to offset such financial hardship (e.g., selling merchandise on the street, forced begging for food and goods) and be a more likely to be abused (campbell, 2020) . for example, it is possible that children will be more likely to be used for child labor and be exploited for sexual behavioral and experience corresponding risk for sexual disease and pregnancy as well as serious psychological distress. interpersonal violence and child abuse will affect children at a significant rate, especially under j o u r n a l p r e -p r o o f conditions wherein there is no oversight from educational systems due to quarantine. world health organizations are already predicting an increase in children who will be orphaned and exposed to abuse and neglect (cluver et al., 2020) . child abuse is less likely to be detected during the covid-19 pandemic because the reduction or lack of child protection agencies monitoring cases, and teachers less able to detect signs of abuse. further, children who received meals at school through government programs such as the national school lunch program may now no longer have access to nutritious food, which can negatively impact their development. the lack of structure from schooling and missed education will have a lasting impact on well-being and apt to be related to increased anxiety, depression, and stress about educational attainment and progress going forward (van lancker & parolin, 2020) . although on-line school may help offset some of these challenges, disparities will exist for those who are most vulnerable, including those who lack internet access or cannot afford technology. older children and young adults may be more likely to drop out of school to help offset family needs. children and youth also may be engaging in more on-line behavior in general or due to emotional distress (e.g., loneliness due to social isolation) and be increasing the chance for solicitation from others who prey on their emotional vulnerabilities (peterman et al., 2020) . lacking access to physical activity due to quarantine protocols may reduce fitness levels and immunological response as well as decrease psychological wellbeing (rundle, park, herbstman, kinsey, & wang, 2020) . children and youth in juvenile systems, such as orphanages, already were exposed to high density living conditions and often lack access to proper medical or psychological care. the covid-19 pandemic is likely to place pressure on such systems (e.g., more children) and the physical environments of these settings may be amenable to the spread of infection. likewise, refugee or otherwise displaced children and youth often live-in high-density environments j o u r n a l p r e -p r o o f wherein social distancing is challenging if not impossible. further, lack of access in these settings to cleaning supplies and water can catalyze the spread of covid-19 or even the basic fear of acquiring the virus. to the extent the covid-19 challenges the medical system, it is possible other forms of medical care necessary for child welfare (e.g., routine exams, immunizations) will be reduced, as was the case during other pandemics such as ebola (mupere, kaducu, & yoti, 2001) . collectively, covid-19 places an enormous stress on children and youth, placing them at an increased risk for psychological disturbances and physical health vulnerability (j. j. liu, bao, huang, shi, & lu, 2020) . covid-19 also will affect ranges of the lifespan, including adults and older adults. the well-publicized health risks for older adults place an obvious psychological and health pressure on this group. older adults are among the most likely to have a chronic illness (e.g., diabetes, cancer, cardiovascular disease) and consequently they maintain an increased vulnerability to deteriorating health and death from covid-19. however, even in the absence of exposure to the virus, the fear and worry about contracting the disease is apt to be significant for this group, especially when in homecare facilities such as nursing homes or hospitals (armitage & nellums, 2020) . this group also is at significant risk for lacking transportation for food, which could challenge the quality of nutrition and have a negative effect in immunological function. similarly, older adults are among the least physical active groups, which again, will have the potential for decreasing psychological wellbeing and immunity. although not specific to older adults, the potential for disruption in grief and loss of others also is a significant psychological stressor. during the pandemic, regular methods of grieving such as funerals have been limited if not all together impossible. the inability to grieve with others or as traditionally done may spur escalation in psychological distress (e.g., sadness, j o u r n a l p r e -p r o o f depression) and complicate the grief process (wallace, wladkowski, gibson, & white, 2020) . to the extent that grief is impaired, individuals may engage in maladaptive addictive behaviors (e.g., alcohol misuse) to cope with the aversive experiences. similar types of emotional reactions may occur when parents are separated from their children due to quarantine protocols and disruptions in travel (e.g., cannot travel to see children located in another region). there are several individual difference factors at a psychological level of analysis that will place people at an increased or decreased risk for psychological problems, addiction, and poor health behavior, and chronic illness during and after the pandemic. research over the past few decades has theorized and found consistent empirical support for emotional symptoms and disorders as well as addictive behavior being explained by individual differences in transdiagnostic processes (sauer-zavala et al., 2012) . transdiagnostic factors may contribute to onset, maintenance, and exacerbation of emotional symptomatology and addictive and health behavior. a core aspect of transdiagnostic models is that they seek to identify basic processes underlying multiple, usually comorbid, psychopathologies or addictive behavior. one set of transdiagnostic factors relevant to covid-19 may be those that are "reactive" vulnerabilities; that is, individual differences that reflect a heightened emotional response to stressful stimuli. such vulnerabilities influence emotion experience by enhancing or diminishing the normative response to emotion stimuli and states, resulting in an excess or deficit, respectively, beyond typical emotional functioning; or altering the type of response to emotion stimuli and states (gratz & roemer, 2004; reiss, 1991; zvolensky, bernstein, & vujanovic, 2011) . in both instances, such reactive processes may be maladaptive because they serve to j o u r n a l p r e -p r o o f reinforce the intensity and frequency of future emotional symptoms. for example, when faced with negative emotion states, individuals with an emotional vulnerability factor that limits their capacity to handle distress may be more apt to execute behaviors that preclude habituation to negative emotion states, which could ultimately increase the intensity of future negative affect and solidify beliefs and learned responses that interfere capacity to adaptively respond to distress. to illustrate, a transdiagnostic factor that may be especially relevant to covid-19 related stress responsivity, substance use, and physical health is anxiety sensitivity (taylor, 2014) . anxiety sensitivity is a malleable, cognitive-affective factor reflecting the tendency to respond to interoceptive distress with anxiety (mcnally, 1989) . anxiety sensitivity is related to, yet distinct from, negative affectivity and trait anxiety (keough, riccardi, timpano, mitchell, & schmidt, 2010) . anxiety sensitivity has demonstrated racial/ethnic, gender, age, and time invariance (ebesutani, mcleish, luberto, young, & maack, 2014; farris et al., 2015; jardin et al., 2018) . given covid-19 can produce physical sensations and even when not infected, covid-related stress can elicit a range of interoceptive sensations, persons higher in anxiety sensitivity may be more be emotional reactive to such stimuli and engage in behavior to dampen stress symptoms (e.g., using tobacco, alcohol). for example, persons may interpret the onset of aversive bodily sensations (e.g., runny nose, cough, fever) as intolerable or catastrophic, exacerbating the experience of such interoceptive symptoms. further, interoceptive symptoms might be particularly salient to persons with higher anxiety sensitivity who are prone to health inequalities (e.g., racial/ethnic minorities, persons in financial stress), as they may be more apt to perceive these internal sensations as uncontrollable because resources to regulate symptoms (i.e., adaptive cognitive and behavioral skills) are likely diminished due to chronic stress exposure j o u r n a l p r e -p r o o f (e.g., low socioeconomic status, discrimination). in turn, persons higher in anxiety sensitivity may be motivated to use substances to reduce emotional and interoceptive distress, elevating their chance for physical illness and compromised immune system function. although this illustrative example represents only one of many possible transdiagnostic amplifying factors, it draws attention to the fact that individual differences in psychological processes are apt to play a central role in the relation between covid-19 related stress and mental health, addictive behavior, health behavior, and chronic illness. individual difference factors also may play roles in offering resilience to covid-19 related stress. that is, individual differences may contribute to the likelihood of a resilient response to covid-19 in the short and long term. thus, in addition to the many situational and contextual factors, individual difference factors will likely shape the level of resiliency to covid-19 pandemic. here, it is likely individual difference factors that de-amplify stress responses will play a central role in offsetting relative risk for psychological, addictive, and health behaviors problems and exacerbation of chronic illness (pidgeon & keye, 2014) . as with affect amplifying factors, such as anxiety sensitivity, there most certainly is a range of factors of potential importance, including flexible coping repertoires, mindfulness, self-efficacy, selfcompassion, and proneness to experience positive affect. to illustrate, individual difference in the capacity to accept difficult covid-19 related stress may offset the potential escalation of anxiety, stress, and depression and mitigate the need for addictive or unhealthy behaviors (e.g., emotional eating) to delimit aversive internal experiences (ranzijn & luszcz, 1999) . consequently, the corresponding risk for health complaints or worsening of chronic health conditions can be offset. indeed, there is a large theoretical and empirical literature that suggests the capacity to accept difficult emotions experiences is related to psychological well-being and j o u r n a l p r e -p r o o f adaptation. for example, one of the reasons meditative practice is related to decreased stress is via change emotional acceptance (teasdale et al., 2002) . this type of work has robust implications in efforts to intervene on covid-19 related stress in the immediate context and for those that struggle to regain stability and growth in the future in terms of mental health, addictive behavior, and health behavior. despite the present lack of systematic empirical work on covid-19 in terms of behavioral health problems, there is good theoretical basis from past scientific work to hypothesize that covid-19 related stress burden, due to a myriad of sources, may play a major vulnerability role in terms of mental health, addictive disorders, and health behaviors as well as chronic illness. for some, the stress-related burden of covid-19 may elicit fundamental changes in risk potential and serve as a fertile basis for future behavioral health problems. for others, the ability to adapt to covd-19 will offer a different course; one that is characterized by greater stability, speed of recovery, and growth. further, it is important to recognize that the adaptation process to covid-19 related stress is apt to be non-linear in many instances. that is, contextual factors (e.g., future life stressors, access to social support) can influence the degree of risk for future problems. research described in this essay provides a basis to develop a theoretical model that could be used to evaluate covid-19 related stress burden on psychological, addictive, and health behaviour problems. we therefore begin this section by briefly outlining a general model that can be used as a heuristic for understanding the complex issues at hand. see figure 1 for a graphical depiction of the model. in general, we predict individual differences in affect amplifying and de-amplifying factors will predict the course of psychological, addictive behavior j o u r n a l p r e -p r o o f and health behavior and chronic illness even when considering differences in exposure to covid-19 experiences (e.g., time of quarantine, acquisition of virus). we would predict, based on past work that transdiagnostic affect amplifying factors will influence addictive and health behaviour, which in turn, will increase (or decrease if de-amplifying) the risk of chronic illness and psychological problems and their comorbidity. further, we can expect that this type of perspective will be moderated by daily stress in the future and access to stress-dampening resources (e.g., social support). accordingly, certain subgroups more prone to greater and more chronic stress, such as first responders and racial/ethnic minorities and orphaned children, may be particularly vulnerable. this conceptual model predicts that the associations which exist between are reciprocal and dynamic. although the model offered here is purposively general and is offered only as a heuristic, it is presumed that there is, in fact, specificity between specific affect amplifying and deamplifying factors, moderators, mediators, and various forms of psychological and chronic illness. that is, a specific type of individual difference factor like anxiety sensitivity is linked to a particular type of problem (e.g., anxiety disorder, worsening of a chronic respiratory illness, severity of hazardous drinking) via a specified mediating process (e.g., smoking, sleep disruption) in the context of certain moderating variables (e.g., higher levels of covid-19 stress burden). the core idea being that the underlying mechanism in this hypothetical example may be quite different from that explaining other problems. the above theoretical model requires empirical testing, and if it is confirmed, one next logical step would be to intervene in it to reduce the burden of mental health, addictive disorders, poor health behaviours, and chronic health conditions related to covid-19 stress burden. ideally, this type of intervention approach would target the root of the pathway, including affect j o u r n a l p r e -p r o o f amplifying (i.e., decreasing levels) and de-amplifying (i.e., promoting growth). however, intervention efforts sit in the fact that the healthcare system will continue to shift and adapt to treatment delivery, including the uptake of digital health technologies. digital health, including mobile health (mhealth), telemedicine/telehealth, and health information technology (e.g., mobile phones, wearable sensors), can be used to develop scalable interventions to promote adherence public health guidelines for mitigating the spread of covid-19. they also can be combined with greater attention to affect amplifying (i.e., decreasing levels) and de-amplifying (i.e., promoting growth) factors that govern many psychological, addictive, and health behaviour processes. here, there is great opportunity for growth of digital health interventions to offer standalone clinical grade therapeutic tactics and as an adjunct to face-to-face interventions. this type of work can close the gap in access to care and offer evidence-based interventions to large segment of society. for example, digital interventions can be used to combat resistance to public health measures at the level of individuals and institutions with a consideration of individual difference factors that affect emotional and behavioral self-regulation. indeed, the public's response to public health measures is itself a potential risk and protective factor for many of the psychological, addictive, and health behavior problems reviewed in this essay. the public health impact of covid-19 on psychological symptoms and disorders, addiction, and health behavior is substantial and ongoing. there is a need for financial and social investment in research to better understand how covid-19 affects the onset, maintenance, and relapse potential for some of the most common, costly, and chronic behavioral health conditions in the general population. further, there is a need for the study of the role of psychological processes, addictive behavior, and health behavior in terms of the onset and maintenance of j o u r n a l p r e -p r o o f covid-19 infection and stress burden. there most certainly will be a demand for preventative and intervention efforts for managing the impact of covid-19 among individuals with elevated negative mood symptoms and disorders, addictive behavior, and certain health behaviors (e.g., sleep disorders) and chronic illness. this work is important to offset the current and projected burden to personal, system, and societal entities, and for providing a theoretical and empirical knowledge base for future pandemics. we presented a heuristic model, which posits that covid-19 related stress and mood, addictive, and health behavior may, in fact, exacerbate each other via several distinct mechanisms. future research in this emerging area has the potential to refine both theory and application with respect to covid-19 and its relation to affect, addiction, and health behavior as well as chronic disease. j o u r n a l p r e -p r o o f • the public health impact of covid-19 on psychological symptoms and disorders, addiction, and health behavior is substantial and ongoing • an integrative covid-19 stress-based model could be used to guide research focused on the stress-related burden of the pandemic • this work could provide a theoretical and empirical knowledge base for future pandemics j o u r n a l p r e -p r o o f how covid-19 may increase domestic violence and child abuse. paper presented at the american psychological association forum the role of stress in the pathogenesis and maintenance of obsessive-compulsive disorder socioeconomic status and health: the challenge of the gradient socioeconomic inequalities in health: no easy solution rates of post-traumatic stress disorder in trauma-exposed children and adolescents: meta-analysis diagnositic and statistical manual of mental disorders covid-19 and the consequences of isolating the elderly. the lancet public health recent developments in understanding ethnocultural and race differences in trauma exposure and ptsd. current opinion in psychology diagnostic and statistical manual of mental disorders: dsm-5 insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies addiction motivation reformulated: an affective processing model of negative reinforcement epidemiology of anxiety disorders in the 21st century chernobyl, 10 years after: health consequences anxiety and its disorders: the nature and treatment of anxiety and panic circadian misalignment and health effects of stress on alcohol drinking: a review of animal studies cognitive paths from trauma to posttraumatic stress disorder: a prospective study of ehlers and clark's model in survivors of assaults or road traffic collisions the role of peri-traumatic stress and disruption distress in predicting symptoms of major depression following investigating the moderating role of culture on the relationship between appraisals and symptoms of posttraumatic stress disorder sleep and immune function covid-19: undocumented migrants are probably at greatest risk. bmj alcohol, stress, and glucocorticoids: from risk to dependence and relapse in alcohol use disorders psychosocial adjustment among children experiencing persistent and intermittent family economic hardship a framework for studying personality in the stress process sleep, immunity, and circadian clocks: a mechanistic model alcohol use during the great recession of smoking upregulates angiotensin-converting enzyme-2 receptor: a potential adhesion site for novel coronavirus sars-cov-2 (covid-19) systematic review of environmental risk factors for obsessive-compulsive disorder: a proposed roadmap from association to causation anxiety symptoms and disorders among adults living with hiv and aids: a critical review and integrative synthesis of the empirical literature immediate antecedents of marijuana use: an analysis from ecological momentary assessment cannabis use vulnerability among socially anxious users: cannabis craving during a social interaction antecedents and consequences of cannabis use among racially diverse cannabis users: an analysis from ecological momentary assessment cannabis use during a voluntary quit attempt: an analysis from ecological momentary assessment cannabis craving in response to laboratory-induced social stress among racially diverse cannabis users: the impact of social anxiety disorder exercise as a treatment to enhance sleep tobacco-use disparity in gene expression of ace2, the receptor of 2019-ncov an increasing risk of family violence during the covid-19 pandemic: strengthening community collaborations to save lives double jeopardy: methamphetamine use and hiv as risk factors for covid-19 daily patterns of substance use and violence among a highrisk urban emerging adult sample: results from the flint youth injury study cognitive appraisal biases: an approach to understanding the relation between socioeconomic status and cardiovascular reactivity in children college student heavy drinking in social contexts versus alone parenting in a time of covid-19 a review of the relationship between emotional learning and memory, sleep, and ptsd economic hardship and its consequences across generations an interactionist perspective on the socioeconomic context of human development clinical profile of participants in a brief intervention program for cannabis use disorder trauma exposure, ptsd, and parenting in a community sample of low-income, predominantly african american mothers and children prevalence and predictors of ptsd among a college sample stability, precision, and near-24-hour period of the human circadian pacemaker change in family income-to-needs matters more for children with less 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 communities in crisis: is there a generalized hiv epidemic in impoverished urban areas of the united states? influence of alcohol consumption on immunological status: a review understanding the construct of impulsivity and its relationship to alcohol use disorders state of telehealth multimorbidity, age-related comorbidities and mortality: association of activation, senescence and inflammation markers in hiv adults a bifactor model of anxiety sensitivity: analysis of the anxiety sensitivity index-3 prevalence of underlying diseases in hospitalized patients with covid-19: a systematic review and meta-analysis. archives of academic emergency medicine the life stress paradigm and psychological distress the environment of poverty: multiple stressor exposure, psychophysiological stress, and socioemotional adjustment do negative beliefs about exposure therapy cause its suboptimal delivery? an experimental investigation evaluation of the anxiety sensitivity index-3 among treatment-seeking smokers smoking, vaping and hospitalization for covid-19 interactive effects of cumulative stress and impulsivity on alcohol consumption the burden of disease associated with being african-american in the united states and the contribution of socio-economic status race, psychosocial vulnerability and social support differences in inner-city women's symptoms of posttraumatic stress disorder the sleep-immunity relationship the role of anxiety in smoking onset, severity, and cessation-related outcomes: a review of recent literature the acute effect of alcohol on decision making in social drinkers sleep in ptsd: conceptual model and novel directions in brain-based research and interventions. current opinion in psychology prevalence of 12-month alcohol use, high-risk drinking, and dsm-iv alcohol use disorder in the united states multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale alcohol use and burden for 195 countries and territories, 1990-2016: a systematic analysis for the global burden of disease study clinical characteristics of coronavirus disease 2019 in china premature age-related comorbidities among hiv-infected persons compared with the general population cardiovascular implications of fatal outcomes of patients with coronavirus disease ethnic and racial differences in the smoking-related risk of lung cancer variation in government responses to covid-19. blavatnik school of government working paper variable insight in ocd perceived control and avoidance in posttraumatic stress a profile of frontline workers in the bay area. bay area equity atlas longitudinal effects of syndemics on art non-adherence among sexual minority men exercise and the prevention of depression: results of the hunt cohort study cannabis effects and dependency concerns in long-term frequent users: a missing piece of the public health puzzle resource loss, resource gain, and depressive symptoms: a 10-year model cancer facts & figures for african americans attempts to stop or reduce marijuana use in non-treatment seekers the role of sleep hygiene in promoting public health: a review of empirical evidence gender-specific effects of an augmented written emotional disclosure intervention on posttraumatic, depressive, and hiv-disease-related outcomes: a randomized, controlled trial why sleep is important for health: a psychoneuroimmunology perspective the effects of exercise on transdiagnostic treatment targets: a meta-analytic review towards a greater understanding of anxiety sensitivity across groups: the construct validity of the anxiety sensitivity index-3 humoral sleep regulation; interleukin-1 and tumor necrosis factor vitamins & hormones maintaining hiv care during the covid-19 pandemic defining and assessing moral injury: a syndrome perspective project trauma support: addressing moral injury in first responders monitoring the future national survey results on drug use traumatization in medical staff helping with covid-19 control anxiety symptomatology: the association with distress tolerance and anxiety sensitivity national estimates of exposure to traumatic events and ptsd prevalence using dsm-iv and dsm-5 criteria ptsd severity among emergency personnel: an investigation based on the ehlers and clark cognitive model socioeconomic status, ethnicity, and risk of coronary heart disease racial discrimination and blood pressure: the cardia study of young black and white adults assessing hiv-related stigma in healthcare settings in the era of the covid-19 pandemic first responder culture: implications for mental health professionals providing services following a natural disaster solitary versus social drinking: an experimental study on effects of social exposures on in situ alcohol consumption the role of gaba a receptors in the acute and chronic effects of ethanol: a decade of progress personal and environmental predictors of posttraumatic stress in emergency management professionals differences in compassion fatigue, symptoms of posttraumatic stress disorder and relationship satisfaction, including sexual desire and functioning, between male and female detectives who investigate sexual offenses against children: a pilot study sense of threat as a mediator of peritraumatic stress symptom development during wartime: an experience sampling study the covid-19 pandemic: a call to action to identify and effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy black-white inequalities in mortality and life expectancy, 1933-1999: implications for healthy people listening to our clients: the prevention of relapse smoking or vaping may increase the risk of severe coronavirus infection inflammation and cardiovascular disease mechanisms covid-19 has inflamed racism against asian-americans. here's how to fight back mental health considerations for children quarantined because of covid-19. the lancet child & adolescent health analysis of factors associated with disease outcomes in hospitalized patients with 2019 novel coronavirus disease lessons learned from hiv can inform our approach to covid-19 stigma hope and posttraumatic stress disorder the oxford handbook of hope cognitive factors in the development, maintenance, and treatment of post-traumatic stress disorder. current opinion in psychology parents in poverty multiple pathways to functional impairment in obsessive-compulsive disorder a multidimensional model of obsessive-compulsive disorder do the daily experiences of healthy men and women vary according to occupational prestige and work strain? psychosomatic medicine optimizing pre-exposure antiretroviral prophylaxis adherence in men who have sex with men: results of a pilot randomized controlled trial of "life-steps for prep stress and the individual: mechanisms leading to disease addiction treatment services and co-occurring disorders: prevalence estimates, treatment practices, and barriers a meta-analysis of cognitive behavior therapy and medication for child obsessive-compulsive disorder: moderators of treatment efficacy, response, and remission the structure of childhood obsessions and compulsions: dimensions in an outpatient sample. behavior, research, and therapy socioeconomic status differences in vulnerability to undesirable life events is anxiety sensitivity distinguishable from trait anxiety? reply to lilienfeld policy challenges in addressing racial disparities and improving population health state of disparities in cardiovascular health in the united states fear of the coronavirus (covid-19): predictors in an online study why do clinicians exclude anxious clients from exposure therapy? behavior, research, and therapy the effect of psychosocial syndemic production on 4-year hiv incidence and risk behavior in a large cohort of sexually active men who have sex with men an initial randomized controlled trial of behavioral activation for treatment of concurrent crystal methamphetamine dependence and sexual risk for hiv acquisition among men who have sex with men prevalence and distribution of e-cigarette use among u.s. adults: behavioral risk factor surveillance system focus on: alcohol and the immune system the insomnia severity index: psychometric indicators to detect insomnia cases and evaluate treatment response role of stress, arousal, and coping skills in primary insomnia ebola haemorrhagic fever among hospitalised children and adolescents in nothern uganda: epidemiologic and clinical observations covid-19: potential implications for individuals with substance use disorders the family model stress and maternal psychological symptoms: mediated pathways from economic hardship to parenting rebalancing the 'covid-19 effect' on alcohol sales the compelling link between physical activity and the body's defense system integrated treatment for smoking cessation, anxiety, and depressed mood in people living with hiv: a randomized controlled trial prevalence of psychiatric and substance abuse symptomatology among hiv-infected gay and bisexual men in hiv primary care cognitive behavioral therapy for trauma and self-care (cbt-tsc) in men who have sex with men with a history of childhood sexual abuse: a randomized controlled trial change in perceived risk associated with marijuana use in the united states from cognitive-behavioral therapy for obsessive-compulsive disorder: a meta-analysis of treatment outcome and moderators is nicotine exposure linked to cardiopulmonary vulnerability to covid-19 in the general population? prioritizing community partners and community hiv workers in the covid-19 pandemic cytokines and sleep experiential avoidance and ptsd emotion in posttraumatic stress disorder global status report on alcohol and health 2018: world health organization alcohol: effects on neurobehavioral functions and the brain anxiety sensitivity and working memory capacity: risk factors and targets for health behavior promotion syndemic indicators predict poor medication adherence and increased healthcare utilization for urban hiv-positive men who have sex with men tobacco and the lung cancer epidemic in china covid-19: risk of increase in smoking rates among england's 6 million smokers and relapse among england's 11 million ex-smokers computer-delivered personalized feedback intervention for hazardous drinkers with elevated anxiety sensitivity: study protocol for a randomized controlled trial pandemics and violence against women and children wider income gaps, wider waistbands? an ecological study of obesity and income inequality relationship between resilience, mindfulness, and pyschological well-being in university students the brown longitudinal obsessive compulsive study: clinical features and symptoms of the sample at intake the relation of perceived and received social support to mental health among first responders: a meta-analytic review intolerance of uncertainty and dsm-5 ptsd symptoms: associations among a treatment seeking veteran sample acceptance: a key to wellbeing in older adults? peritraumatic unconditioned and conditioned responding explains sex differences in intrusions after analogue trauma obsessive compulsive disorder and comorbidity long-term cannabis use: characteristics of users in an australian rural area expectancy model of fear, anxiety, and panic covid-19: disproportionate impact on ethnic minority healthcare workers will be explored by government moderate alcohol consumption and the immune system: a review covid-19 related school closings and risk of weight gain among children the epidemiology of obsessive-compulsive disorder in the national comorbidity survey replication cognitive behavioral therapy for adherence and depression (cbt-ad) in hivinfected injection drug users: a randomized controlled trial project enhance: a randomized controlled trial of an individualized hiv prevention intervention for hiv-infected men who have sex with men conducted in a primary care setting smoking trends and disparities among black and non-hispanic whites in california why child welfare experts fear a spike of abuse during covid-19 relationship between household income and mental disorders: findings from a population-based longitudinal study the role of negative affectivity and negative reactivity to emotions in predicting outcomes in the unified protocol for the transdiagnostic treatment of emotional disorders a test of the family stress model on toddler-aged children's adjustment among hurricane katrina impacted and nonimpacted low-income families trauma cognitions are related to symptoms up to 10 years after cognitive behavioral treatment for posttraumatic stress disorder the role of mindfulness in protecting firefighters from psychosomatic malaise estimating the risk of ptsd in recent trauma survivors: results of the international consortium to predict ptsd (icpp) the burden of covid-19 in people living with hiv: a syndemic perspective posttraumatic stress disorder in african american and latinx adults: clinical course and the role of racial and ethnic discrimination covid-19 infection in children. the lancet explaining social class differences in depression and well-being. social psychiatry and psychiatric epidemiology work characteristics and psychiatric disorder in civil servants in london predictors of ptsd 40 years after combat: findings from the national vietnam veterans longitudinal study obsessive-compulsive disorder -w substance abuse and mental health services administration center for behavioral health statistics and quality early epidemiological analysis of the coronavirus disease 2019 outbreak based on crowdsourced data: a population-level observational study. the lancet digital health a recent perspective on alcohol, immunity, and host defense pulmonary effects of inhaled cannabis smoke a new covid-19 crisis: domestic abuse rises worldwide anxiety sensitivity: theory, research, and treatment of the fear of anxiety: routledge metacognitive awareness and prevention of relapse in depression: empirical evidence coping strategies as mediators in relation to resilience and posttraumatic stress disorder potent binding of 2019 novel coronavirus spike protein by a sars coronavirus-specific human monoclonal antibody. emerging microbes & infections secular trends in smoking in relation to prevalent and incident smoking-related disease: a prospective population-based study ace2: from vasopeptidase to sars virus receptor the age of anxiety? the birth cohort change in anxiety and neuroticism covid-19, school closures, and child poverty: a social crisis in the making covid-19 and smoking: a systematic review of the evidence. tobacco induced diseases respiratory failure caused by lipoid pneumonia from vaping e-cigarettes increased use of cigarettes, alcohol, and marijuana among manhattan posttraumatic stress and substance use disorders: a comprehensive clinical handbook distress tolerance and posttraumatic stress grief during the covid-19 pandemic: considerations for palliative care providers receptor recognition by the novel coronavirus from wuhan: an analysis based on decade-long structural studies of sars coronavirus immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china susceptibility analysis of covid-19 in smokers based on ace2 recommended amount of sleep for a healthy adult: a joint consensus statement of the american academy of sleep medicine and sleep research society using death certificates to explore changes in alcohol-related mortality in the united states trends in meeting physical activity guidelines among urban and rural dwelling adults-united states income inequality and population health: a review and explanation of the evidence the problems of relative deprivation: why some societies do better than others. social science & medicine income inequality and socioeconomic gradients in mortality social sources of racial disparities in health racial/ethnic discrimination and health: findings from community studies racial differences in physical and mental health: socio-economic status, stress and discrimination occupational moral injury and mental health: systematic review and meta-analysis evolution of the novel coronavirus from the ongoing wuhan outbreak and modeling of its spike protein for risk of human transmission covid-19 and african americans patients with mental health disorders in the covid-19 epidemic epidemiology of exercise and sleep survey of insomnia and related social psychological factors among medical staff novel coronavirus disease outbreak clinical characteristics of 140 patients infected with sars-cov-2 in wuhan single-cell rna expression profiling of ace2, the receptor of sars-cov-2 a pneumonia outbreak associated with a new coronavirus of probable bat origin coronavirus infections in children including covid-19: an overview of the epidemiology, clinical features, diagnosis, treatment and prevention options in children. the pediatric infectious disease journal are the high smoking rates related to covid-19 outbreaks? distress tolerance: theory, research, and clinical applications we wish to draw the attention of the editor to the following facts which may be considered as potential conflicts of interest and to significant financial contributions to this work zvolensky receives personal fees from elsevier, guilford press, and is supported by grants from nih he receives research support from nih, texas higher education coordinating board, rebuild texas and greater houston community fund. he receives travel support and honorarium from iocdf for training in ocd treatment schmidt is supported by the military suicide research consortium (msrc), department of defense, and visn 19 mental illness research, education, and clinical center buckner receives funding from the u.s. department of health & human services' graduate psychology education (gpe) program (grant d40hp33350) smits reports grants from cancer prevention and research institute of texas; personal fees from big health, ltd., personal fees from aptinyx, inc., personal fees from elsevier vujanovic receives book royalties from routledge press and is supported, in part cleirigh is supported by grants from the nih and the centers for disease control and prevention we confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed he/she is responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs. we confirm that we have provided a current, correct email address which is accessible by the corresponding author and which has been configured to accept email from mjzvolen@central