UK COVID-19 outbreak – 38% of population reported significant symptoms of depression

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There was a spike in the number of people reporting significant levels of depression and anxiety immediately following the Prime Minister’s announcement of a lockdown on 23 March, a study has found.

On Tuesday 24 March, 38 percent of study participants reported significant depression and 36 percent reported significant anxiety.

On the day before the announcement, 16 percent reported significant depression and 17 percent reported significant anxiety.

Rates remained elevated later in the week, but not as high as immediately after the announcement, with just over 20 percent on each subsequent day reporting significant levels of depression and anxiety, according to the large representative study of the pandemic’s impact on mental health.

The research, conducted by academics at the University of Sheffield and Ulster University, indicated that many people are nonetheless remaining resilient and faring well – and that almost everyone is following government advice to avoid spreading the virus.

The team of experts, led by Professor Richard Bentall at the University of Sheffield, carried out a psychological survey of 2,000 people between Monday 23 March and Friday 27 March using standardised measures of mental health.

Participants, who were representative of the population in terms of age, sex and income, were asked in an online survey about their current circumstances, their understanding of COVID-19, what they are doing to cope, and psychological symptoms.

Across the week, the study found that 25 percent of women and 18 percent of men exhibited clinically meaningful symptoms of anxiety, 23 percent of women and 21 percent of men showed signs of depression, and 15 percent of women and 19 percent of men were stressed.

These results are elevated compared to those of similar surveys from before the coronavirus crisis, such as the Adult Psychiatric Morbidity Survey (in which 15.7 percent reported common psychiatric disorders), but not dramatically so.

However, those aged under 35, living in a city, living alone or with children, with lower incomes, with health conditions and those whose incomes had been hit by the pandemic had higher rates of anxiety and depression.

Those who felt that they belonged to their neighbourhood and who trusted their neighbours had lower levels of anxiety and depression.

The study found that 32 percent of people had already lost income due to the pandemic, but when asked to rate their level of worry about the financial impact so far on a scale of 0 (not worried at all) to 10 (extremely worried), the average response was around six.

The team asked participants how much they had increased their purchasing of key supplies because of the pandemic.

While around 30 percent had bought extra dried food, tinned food and toilet roll, most people reported very little excess buying and almost a quarter (23.6 percent) reported none at all.

The study found a modest correlation between anxiety about COVID-19 and over-purchasing.

The population was found to have a good understanding of COVID-19 symptoms and how to avoid spreading it – with over 90 percent of those surveyed correctly identifying symptoms such as coughing and a fever, and recognising that it can spread through people coughing or sneezing.

Almost 95 percent of participants said they had started washing their hands more often, 91 percent said they covered their nose or mouth with a tissue or sleeve when coughing and sneezing, and 78 percent were disinfecting household surfaces more frequently.

The initial results show a majority of the population taking further steps to protect their health – with 69 percent ensuring they get enough sleep and two-thirds saying they are eating a more balanced diet.

About 70 percent said that they would definitely want to be vaccinated, or would want their children to be vaccinated, against the coronavirus if this was available.

However, on average people thought their risk of catching the virus in next month was less than 50 percent.

The research, conducted by academics at the University of Sheffield and Ulster University, indicated that many people are nonetheless remaining resilient and faring well – and that almost everyone is following government advice to avoid spreading the virus.

When asked where they get their information about the epidemic and what sources of information they trust, people scored their doctor and other health professionals as the most trustworthy – but said they get most of their information from the television.

The team will survey the same group again in the coming months to see how their experiences, beliefs and mental health symptoms change as the pandemic progresses in the UK, and to compare their results with parallel surveys being conducted by research partners in other countries.

Professor Richard Bentall, Professor of Clinical Psychology at the University of Sheffield, said: “We were surprised to see a spike in the number of people reporting significant levels of depression and anxiety immediately after the announcement of a lockdown.

“We are seeing initial evidence of a rise in psychological symptoms in the population but, nonetheless, the overall picture that emerges so far is of a nation that is well-informed about Covid-19, taking appropriate action and resilient.

The rates of reported mental health problems are higher but not dramatically different to those observed in previous, similar surveys – but those who have already taken a financial hit are more likely to feel anxious or depressed.

“In the coming months we will be able to see if these groups show an escalation of symptoms and also whether some social adjustments to the pandemic – for example increased sense of belonging to neighbourhoods or groups – help to protect the population from mental health symptoms.”


The 2019 coronavirus disease (COVID-19) epidemic in China is a global health threat [1], and is by far the largest outbreak of atypical pneumonia since the severe acute respiratory syndrome (SARS) outbreak in 2003. Within weeks of the initial outbreak the total number of cases and deaths exceeded those of SARS [2].

The outbreak was first revealed in late December 2019 when clusters of pneumonia cases of unknown etiology were found to be associated with epidemiologically linked exposure to a seafood market and untraced exposures in the city of Wuhan of Hubei Province [3].

Since then, the number of cases has continued to escalate exponentially within and beyond Wuhan, spreading to all 34 regions of China by 30 January 2020.

On the same day, the World Health Organization (WHO) declared the COVID-19 outbreak a public health emergency of international concern [4].

COVID-19, similarly to SARS, is a beta-coronavirus that can be spread to humans through intermediate hosts such as bats [5], though the actual route of transmission is still debatable.

Human-to-human transmission has been observed via virus-laden respiratory droplets, as a growing number of patients reportedly did not have animal market exposure, and cases have also occurred in healthcare workers [6].

Transmissibility of COVID-19 as indicated by its reproductive number has been estimated at 4.08 [7], suggesting that on average, every case of COVID-19 will create up to 4 new cases. The reporting rate after 17 January 2020 has been considered to have increased 21-fold in comparison to the situation in the first half of January 2020 [8].

The average incubation period is estimated to be 5.2 days, with significant variation among patients [9], and it may be capable of asymptomatic spread [10,11]. Symptoms of infection include fever, chills, cough, coryza, sore throat, breathing difficulty, myalgia, nausea, vomiting, and diarrhea [12].

Older men with medical comorbidities are more likely to get infected, with worse outcomes [12]. Severe cases can lead to cardiac injury, respiratory failure, acute respiratory distress syndrome, and death [13].

The provisional case fatality rate by WHO is around 2%, but some researchers estimate the rate to range from 0.3% to 0.6% [14].

Since the outbreak, response efforts by the China government have been swift, and three weeks into the epidemic, in an unprecedented move to retard the spread of the virus, a lockdown was imposed on Wuhan on 23 January, with travel restrictions.

Within days, the quarantine was extended to additional provinces and cities, affecting more than 50 million people in total. Many stayed at home and socially isolated themselves to prevent being infected, leading to a “desperate plea” [15]. There have also been accounts of shortages of masks and health equipment.

The ongoing COVID-19 epidemic is inducing fear, and a timely understanding of mental health status is urgently needed for society [16]. Previous research has revealed a profound and wide range of psychosocial impacts on people at the individual, community, and international levels during outbreaks of infection.

On an individual level, people are likely to experience fear of falling sick or dying themselves, feelings of helplessness, and stigma [17]. During one influenza outbreak, around 10% to 30% of general public were very or fairly worried about the possibility of contracting the virus [18].

With the closure of schools and business, negative emotions experienced by individuals are compounded [19]. During the SARS outbreak, many studies investigated the psychological impact on the non-infected community, revealing significant psychiatric morbidities which were found to be associated with younger age and increased self-blame [20].

Those who were older, of female gender, more highly educated, with higher risk perceptions of SARS, a moderate anxiety level, a positive contact history, and those with SARS-like symptoms were more likely to take precautionary measures against the infection [21].

Currently, there is no known information on the psychological impact and mental health of the general public during the peak of the COVID-19 epidemic.

This is especially pertinent with the uncertainty surrounding an outbreak of such unparalleled magnitude. Based on our understanding, most of the research related to this outbreak focuses on identifying the epidemiology and clinical characteristics of infected patients [6,12], the genomic characterization of the virus [22], and challenges for global health governance [23]. However, there are no research articles examining the psychological impact on COVID-19 on the general population in China.

Therefore, this present study represents the first psychological impact and mental health survey conducted in the general population in China within the first two weeks of the COVID-19 outbreak.

This study aims to establish the prevalence of psychiatric symptoms and identify risk and protective factors contributing to psychological stress. This may assist government agencies and healthcare professionals in safeguarding the psychological wellbeing of the community in the face of COVID-19 outbreak expansion in China and different parts of the world.

Discussion

Our findings suggest that with respect to the initial psychological responses of the general public from 31 January to 2 February 2020, just two weeks into the country’s outbreak of COVID-19 and one day after WHO declared public health emergency of international concern, 53.8% of respondents rated the psychological impact of outbreak as moderate or severe; 16.5% of respondents reported moderate to severe depressive symptoms; 28.8% of respondents reported moderate to severe anxiety symptoms; and 8.1% reported moderate to severe stress levels.

The prevalence of moderate or severe psychological impact as measured by IES-R was higher than the prevalence of depression, anxiety, and stress as measured by the DASS-21.

The difference between IES-R and DASS-21 is due to the fact that the IES-R assesses the psychological impact after an event. In this study, respondents might refer the COVID-19 outbreak as the event while the DASS-21 did not specify any such event.

In this study, the majority of respondents spent 20–24 h per day at home (84.7%), did not report any physical symptoms (60.81%), and presented with good self-rated health status (68.3%).

In this study, very few respondents had a direct or indirect contact history with individuals with confirmed or suspected COVID-19, or had undergone medical consultations related to COVID-19 (≤1%).

The majority of respondents (>70%) were worried about their family members contracting COVID-19, but they believed that they would survive if infected.

Overall, the Internet (93.5%) was the primary health information channel for the general public during the initial stage of COVID-19 epidemic in China. Nearly all respondents (>90%) requested regular updates on the latest information on the route of transmission, availability and effectiveness of medicines/vaccines, travel advice, overseas experience in handling COVID-19, number of cases and location, advice on prevention, more tailored information (e.g., for people with chronic illnesses), information on outbreaks in the local area, and details on symptoms.

The majority of respondents (>70%) were satisfied with the amount of health information available. More than half of the respondents washed their hands with soaps after touching contaminated objects, covered their mouth when coughing or sneezing, and wore masks regardless of the presence or absence of symptoms as precaution strategies.

As the COVID-19 epidemic continues to spread, our findings will provide vital guidance for the development of a psychological support strategy and areas to prioritize in China and other places which are affected by the epidemic.

As the epidemic is ongoing, it is important to prepare health care systems and the general public to be medically and psychologically ready if widespread transmission occurs outside China [32]. Our findings have clinical and policy implications.

First, health authorities need to identify high-risk groups based on sociodemographic information for early psychological interventions. Our sociodemographic data suggest that females suffered a greater psychological impact of the outbreak as well as higher levels of stress, anxiety, and depression.

This finding corresponds to previously extensive epidemiological studies which found that women were at higher risk of depression [33]. Students were also found to experience a psychological impact of the outbreak and higher levels of stress, anxiety, and depression.

As the total number of people infected by COVID-19 currently surpasses those stricken by the 2003 SARS-CoV epidemic, major cities in China have shut down schools at all levels indefinitely.

The uncertainty and potential negative impact on academic progression could have an adverse effect on the mental health of students. During the epidemic, education authorities need to develop online portals and web-based applications to deliver lectures or other teaching activities [34].

As young people are more receptive towards smartphone applications [35], health authorities could consider providing online or smartphone-based psychoeducation and psychological interventions (e.g., cognitive behavior therapy, CBT) to reduce risk of virus transmission by face-to-face therapy. Online platforms could also provide a support network for those people spending most of their time at home during the epidemic.

We found that the general public with no formal education had a greater likelihood of depression during the epidemic. Local agencies need to provide information in a diagrammatic or audio format in simple languages to support those with no educational background during the epidemic.

Second, health authorities need to identify the immediate psychological needs of the general population presenting with physical symptoms during the epidemic. Our results revealed that the general population presenting with specific symptoms including chills, coryza, cough, dizziness, myalgia, and sore throat, as well as those with poor self-rated health status and history of chronic illnesses, experienced a psychological impact of the outbreak and higher levels of stress, anxiety, and depression.

After presentation to the clinic or hospital with the above physical symptoms, patients may be sent home, quarantined, or admitted for further investigation. Health professionals should take the opportunity to provide resources for psychological support and interventions for those who present with the above symptoms, especially during hospitalization. Taking a family history is essential, and health professionals should enquire about the level of concern for other family members, especially children, of contracting COVID-19, as these concerns are associated with stress and anxiety, respectively.

Third, government and health authorities need to provide accurate health information during the epidemic to reduce the impact of rumors [23]. Higher satisfaction with the health information received was associated with a lower psychological impact of the outbreak and lower levels of stress, anxiety, and depression.

The content of health information provided during the epidemic needs to be based on evidence to avoid adverse psychological reactions. Our results showed that up-to-date and accurate health information, especially on the number of recovered individuals, was associated with lower stress levels.

Additional information on medicines or vaccines, routes of transmission, and updates on the number of infected cases and location (e.g., real-time, online tracking map) were associated with lower levels of anxiety.

Fourth, the content of psychological interventions (for example CBT) needs to be modified to suit the needs of the general population during the epidemic. CBT should preferably be delivered online or via telephone to avoid the spread of infection.

As online CBT does not require the presence of mental health professionals (e.g., psychologists), this will be helpful to the general public in China as there is a shortage of psychologists.

Based on our findings, cognitive therapy can provide information or evidence to enhance confidence in the doctor’s ability to diagnose COVID-19.

Cognitive therapy can challenge cognitive bias when recipients overestimate the risk of contracting and dying from COVID-19. As the majority of the general population in this study was homebound for 20–24 h per day during the epidemic, behavior therapy could focus on relaxation exercises to counteract anxiety and activity scheduling (e.g., home-based exercise and entertainment) to counteract depression in the home environment.

Self-administered acupressure and emotional freedom techniques derived from key principles within traditional Chinese medicine are potential interventions which may benefit the mental health of general public during the COVID-19 outbreak. Further research Is required to evaluate the effectiveness of these interventions.

Fifth, our findings suggest that the precautionary measures adopted to prevent the spread of COVID-19 could have had protective psychological effects during the early stage of the epidemic. During the 2003 SARS-CoV epidemic, researchers found that moderate levels of anxiety were associated with higher uptake of preventive measures by respondents [21]. Our findings showed the opposite trend.

Specific precautionary measures including avoidance of sharing utensils (e.g., chopsticks), hand hygiene, and wearing masks regardless of the presence or absence of symptoms were associated with lower levels of psychological impact, depression, anxiety, and stress.

The experiences of the 2003 SARS-CoV epidemic could have changed the perception of the general public towards precautionary measures and have led to a positive effect on the initial psychological responses to the COVID-19 epidemic by giving respondents confidence and sense of control in prevention.

As the Chinese prefer to use chopsticks to pick up food commonly shared on a plate during mealtime as part of their culture, it is not unexpected that avoidance of sharing utensils (e.g., chopsticks) during meals is significantly associated with less psychological impact and lower levels of anxiety, depression, and stress.

During the initial stage of the COVID-19 epidemic, health authorities outside China had different recommendations for mask usage due to a global shortage of masks. While some health authorities urged citizens not to wear masks if they were well (e.g., Singapore), other health authorities urged their citizens to always have masks and hand sanitizers ready (e.g., Malaysia, Vietnam) [36].

The official guidance from the World Health Organization (WHO) advises that healthy people should only wear masks if they are taking care of a person with suspected COVID-19 infection or if people are coughing and sneezing [37]. Our study found that wearing masks, regardless of the presence or absence of symptoms, was associated with lower levels of anxiety and depression.

Although the WHO emphasizes that masks are effective only when used in combination with frequent hand-cleaning with alcohol-based hand rub or soap and water, wearing a mask regardless of the presence or absence of symptoms could offer potential psychological benefits by offering a sense of security.

This finding was anticipated because wearing face masks is a common practice when people are sick or to counter urban pollution or haze in parts of Asia, including China [38].

Governments and health authorities should ensure there are infrastructures to produce and provide an adequate supply of masks, soaps, alcohol-based hand rubs, and other personal hygiene products during the COVID-19 epidemic.

This study has several limitations. Given the limited resources available and time-sensitivity of the COVID-19 outbreak, we adopted the snowball sampling strategy. The snowballing sampling strategy was not based on a random selection of the sample, and the study population did not reflect the actual pattern of the general population.

Furthermore, it would be ideal to conduct a prospective study on the same group of participants after a period. Due to ethical requirements on anonymity and confidentiality, we were not allowed to collect contact details and personal information from the respondents. As a result, we could not conduct a prospective study that would provide a concrete finding to support the need for a focused public health initiative.

There was an oversampling of a particular network of peers (e.g., students), leading to selection bias. As a result, the conclusion was less generalizable to the entire population, particularly less educated people. Another limitation is that self-reported levels of psychological impact, anxiety, depression and stress may not always be aligned with assessment by mental health professionals.

Similarly, respondents might have provided socially desirable responses in terms of the satisfaction with the health information received and precautionary measures. Lastly, the number of respondents with contact history and who had sought medical consultations was very small. Our findings could not be generalized to confirmed or suspected cases of COVID-19.

Notwithstanding the above limitations, this study provides invaluable information on the initial psychological responses 2 weeks after the outbreak of COVID-19 from respondents across 194 cities in China. Our results could be used as a historical reference.

Most importantly, our findings directly inform the development of psychological interventions that can minimize psychological impact, anxiety, depression, and stress during the outbreak of COVID-19 and provide a baseline for evaluating prevention, control, and treatment efforts throughout the remainder of the COVID-19 epidemic, which is still ongoing at the time of preparing this manuscript.


Source:
University of Sheffield

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