ABSTRACT
This study aimed to investigate the relationship between depression, anxiety, and stress levels in individuals and sociodemographic characteristics and worries and attitudes towards the pandemic during the coronavirus disease-2019 (COVID-19) outbreak.
This cross-sectional study was conducted using an online survey. Participants were evaluated using a sociodemographic data form, the COVID-19 worry and attitude questionnaire, the depression anxiety and stress scale (DASS-21), and the impact of event scale-revised (IES-R).
A total of 633 respondents were included in the study. In total, 23.2% (n=122) of respondents rated the psychological impact of the outbreak as moderate or severe (IES-R >33). Moderate, severe, and very severe depression, anxiety, and stress levels were determined in 29.7% (n=188), 19% (n=122), and 13.4% (n=85) of respondents, respectively. Binary logistic regression analysis showed that gender, accompanying chronic disease, employment status, COVID-19 contact history, poor self-rated health status, and worries related to the pandemic were factors significantly associated with the DASS-21 and IES-R scores.
The mental health of individuals was negatively affected by worries about socioeconomic and pandemic-related uncertainties during the COVID-19 pandemic. Social and health policies should be planned to reduce individual concerns during the pandemic.
INTRODUCTION
Coronavirus disease-2019 (COVID-19) pandemic, which started in Wuhan, China in December 2019, spread globally in a short period. As of 11 March 2020, when the virus was detected in Turkey for the first time, the government implemented several measures, including school closures, stay-at-home orders, and lockdowns. In many countries where the virus has spread, individuals have been warned through health institutions and the media to obey social distancing rules and restrict themselves from social environments. Uncertainty in education, social life, and business life has gradually increased (1).
Under these negative conditions, studies have shown that the rates of anxiety and depression are high among individuals during the pandemic. In a study conducted in China, 53.8% of respondents rated the psychological impact of the outbreak as moderate or severe; 16.5% reporting moderate or severe depression symptoms, 28.8% reporting moderate or severe anxiety symptoms, and 8.1% reporting moderate or severe stress symptoms (2). Studies have reported percentages of post-traumatic stress symptoms as 7% and 15.8% (3, 4). Several studies have reported risk factors for anxiety and depression. Female gender (2, 5, 6), urban residence (6), low self-rated health status (2), accompanying chronic disease (5, 6), and contact history of suspected or confirmed cases (2) are defined risk factors.
Descriptive studies investigating the concerns of individuals during the pandemic are limited. Concerns are defined as repetitive negative or catastrophic thoughts accompanied by worries about uncertain circumstances (7, 8). During the pandemic, individual concerns may be related to health anxiety as well as many other conditions, such as social and economic uncertainty, uncertainties about protection from the virus and treatment, and social restrictions. Concerns can be a factor in mobilizing individuals to deal with potential threats and increase protective behaviors (wearing masks) that can mitigate threats (7, 9). However, increased intense worry is associated with increased mental health problems in individuals (8, 10). Defining the extent to which individuals are affected by these concerns will help determine the risks of mental illness and take appropriate precautions.
This study aims to investigate pandemic-related worries and their effects on anxiety and depression levels.
METHODS
An online questionnaire was designed to investigate the psychological responses of individuals over the age of 17 living in various provinces of Turkey to the COVID-19 pandemic. The Karadeniz Technical University Faculty of Medicine Scientific Research Ethics Committee approved the study (approval number: 24237859-379, date: 19.06.2020). After approval, data were collected through an online questionnaire for four weeks. Individuals who read the informed consent form about the study via social media were asked to fill out the questionnaire. Google Docs software was used to collect data. This study was conducted in accordance with the principles of the Helsinki Declaration.
The sociodemographic data form includes age, gender, education level, income level, marital status, with whom he/she lives (living situation), having children, employment status for the last 14 days, direct or indirect contact history with COVID-19, and accompanying chronic disease. In addition, the participants were asked to rate their physical health.
In the COVID-19 worry and attitude questionnaire, participants were asked to rate each statement related to the COVID-19 pandemic (e.g., are you worried about spreading the virus to others? Are you worried about experiencing financial difficulties?). The questionnaire was designed as a 5-point Likert-type feedback survey (0= Never, 4= Almost always). The items of precautionary behaviors in the questionnaire were hand washing/disinfection, wearing a mask, and avoiding close contact. The internal consistency of the survey was found to be good (Cronbach’s alpha =0.864).
The depression anxiety and stress scale (DASS-21) was developed by Lovibond and Lovibond (11). This scale consists of 21 items, and its validity and reliability with clinical and non-clinical samples in Turkey were demonstrated (12). It contains 7 items for each subscale, and each item is scored between 0 (never) and 3 (almost always). Items 3, 5, 10, 13, 16, 17, and 21 of the scale assess the level of depression; items 2, 4, 7, 9, 15, 19, and 20 measure the level of anxiety; and items 1, 6, 8, 11, 12, 14, and 18 assess the level of stress. According to the total score of the depression subscale, the following categorization is made: normal (0-4), mild depression (5-6), moderate depression (7-10), severe depression (11-13), and very severe depression (14 and above). According to the total score of the anxiety subscale, (0-3) is graded as normal, (4-5) mild, (6-7) moderate, (8-9) severe, and (10 and above) very severe. The total score of the stress subscale was graded as normal (0-7), mild (8-9), moderate (10-12), severe (13-16), and very severe (17 and above).
Psychological impact was assessed using the impact of event scale-revised (IES-R). The IES-R is a self-report scale consisting of 22 items that measures the level of symptoms experienced in the last 7 days between 0 (none) and 4 (very much). It comprises three subscales: avoidance of traumatic events, over-arousal, and re-experiencing (13). In the validity and reliability study of the Turkish version of the scale, the cut-off value of the scale was found to be between 24-33, sensitivity to be between 74.0-92.2%, and specificity to be between 70.7-81.0% (14).
While the data were included in the paired comparison analysis, to identify individuals with high levels of worry, the items of the COVID-19 worry and attitude questionnaire were grouped as follows: often; almost always (high); never; rarely; and sometimes (low). Self-rated health status was analyzed as good-very good (high) and moderate-bad-very bad (low). To identify individuals with high psychological burden, we detected individuals with moderate, severe, and very severe DASS-21 depression, anxiety, and stress levels. A score of 33 was included in the analysis as the cut-off score on the IES-R scale. IBM SPSS for Windows 23.0 statistics software package (Armonk, New York: IBM Corp.) was used for data analysis. Categorical data are presented as numbers (n) and percentages (%). Binary logistic regression analysis was used to detect factors that predicted high DASS-21 scores for depression, anxiety, stress, and IES-R. Test validity was determined using the omnibus test and the Hosmer-Lemeshow test. Explanatoriness of the regression analysis was determined using Nagelkerke R2. Logistic regression test results were presented using odds ratio and 95% confidence interval values. The cases where p≤0.05 were accepted as statistically significant.
RESULTS
A total of 633 participants completed the survey. Of the participants, 18.2% (n=115) were students, 42.2% (n=267) were actively employed, 22.7% (n=144) had flexible working arrangements (furloughed-rotation, working from home), and 16.9% (n=107) were unemployed. Of the entire group, 29.7% (n=188) had moderate, severe, or very severe depression, 19.3% (n=122) had moderate, severe, or very severe anxiety, %13.4 (n=85) had moderate, severe, or very severe stress. The IES-R score was detected above 33 points in 23.2% (n=147) of the patients. The severity of DASS-21 and IES-R scores and COVID-19 worry and attitude questionnaire scores are summarized in Table 1.
In the regression analysis, the variables that predicted moderate, severe, and very severe DASS-21 depression were active and flexible working, low self-rated health status, worry about social restrictions, financial difficulties, social breakdown, and getting COVID-19 test. (Nagelkerke R square =0.356, Hosmer- Lemeshow =0.476). The variables that predicted moderate, severe, and very severe DASS-21 anxiety were low self-rated health status, worry about spreading the virus to others, death of relatives from COVID-19, social restrictions, social breakdown, and access to adequate health care. Wearing a mask was significantly related to a decrease in individuals’ anxiety levels (Nagelkerke R square =0.406, Hosmer-Lemeshow =0.720). In the regression analysis, the variables that predicted moderate, severe, and very severe DASS-21 stress were active working, contact history, worry about social restrictions, social breakdown, access to adequate health care, and taking the COVID-19 test (Nagelkerke R square =0.389, Hosmer-Lemeshow =0.725). The variables predicting high IES-R scores were flexible working, low self-rated health status, worry about spreading the virus to others, death of relatives from COVID-19, social restriction, social breakdown, and death from COVID-19 (Nagelkerke R square =0.394, Hosmer-Lemeshow =0.713) (Table 2).
DISCUSSION
In this descriptive study, it was observed that the most intense concerns of the participants during the pandemic were spreading the virus to others, getting infected, or the death of relatives. In addition, worries that commonly affected the participants’ mental health included social restrictions and being alone. Additionally, 24.3% of the participants reported intense concerns about financial difficulties, 24.9% reported concerns about a social breakdown, and 14% stated their concerns about access to adequate health care. These results show that uncertainties regarding economic, social, and COVID-19 treatment cause worries in a significant percentage of the participants.
We found that worries about social restrictions have significant adverse effects on depression, anxiety, and stress levels in patients. Long-term social restrictions have been reported to lead to many negative consequences, such as a decrease in close interpersonal relationships, separation from friends and family, and a sense of loneliness (15-18). Previous studies have reported increased depression, stress, sleep disturbance, irritability, post-traumatic stress symptoms, and suicide risk among individuals during quarantine and isolation periods (19-22). Thus, while warning individuals to remain isolated during pandemics, it is important to educate and advise individuals on dealing with the negative mental effects of restrictions (23).
In this study, participants’ concerns about financial difficulties were associated with an increase in the severity of depression. The COVID-19 pandemic has increased fears of economic crisis and recession, and widespread restrictions have caused economic uncertainty (24). In line with our study results, during the pandemic, it was reported that an increasing level of economic anxiety developed in individuals living in the community (25, 26). We found that economic anxiety significantly predicted the severity of depression. Furthermore, we found that employment was associated with a decrease in depression, stress, and the psychological impact of the event. Consistent with our findings, having a regular income and working were found to be protective factors for mental health during the pandemic (3, 17, 27). On the other hand, the finding that worry about a social breakdown is a predictor on all scales in our study suggests that the socioeconomic uncertainty caused by the pandemic has led to widespread negative effects on individuals’ mental health. In a previous study that investigated the most common worries of individuals related to the pandemic, participants reported many common major worries about social breakdown. The researchers emphasized that in the socioeconomic uncertainty, most individuals were concerned about the devastating impact of the virus on the health system, economy, and society (7). In addition to uncertainty, repetitive media exposure to community crises during the pandemic can lead to a higher perception of the current risk (7, 28). The negative effects of these worries on mental health demonstrate that social policies for the pandemic should be well-planned.
In this study, we determined that flexible working causes a decrease in IES-R scores. After the pandemic, a significant proportion of workers switched to remote work. It was reported that individuals who worked remotely during the pandemic were psychologically less affected by the event than active workers (27). Remote work and break periods can reduce the risk of exposure to COVID-19 and related concerns.
This study revealed that concerns about access to adequate healthcare were associated with participants’ anxiety and stress levels. At the beginning of the pandemic, uncertainty regarding the treatment of COVID-19 was substantial. Hospitals and intensive care units were filled with patients with COVID-19. These developments may have led to an increase in treatment-related concerns. In connection with these worries, the present study found that worry about getting the COVID-19 test predicted depression and stress levels. Furthermore, some negative situations that may arise in cases in which the test is positive could trigger worry about getting tested: isolation, stigmatization, job loss, etc.
Another finding to emphasize is that the accompanying chronic disease was associated with the psychological impact of the event. These results imply that it is important to implement measures to protect vulnerable groups against the virus during the pandemic. Furthermore, self-rated health status was strongly correlated with levels of anxiety, depression, and the psychological impact of the event. These data are consistent with previous studies (2, 5, 29, 30). Individuals who do not perceive their physical health well may worry about being infected or become more vulnerable to the virus. On the other hand, the stressful environment of the pandemic or the accompanying anxiety and depression can increase physical symptoms (31). Therefore, during the pandemic, individuals who do not find their physical health conditions appealing should be evaluated for accompanying mental disorders (2).
Consistent with our findings, worries about spreading the virus to others and the health of relatives were the most frequently reported concerns during the pandemic (2, 7, 26, 32). We found that these worries significantly predicted high anxiety levels. Concerns about the health of relatives are consistent with data showing that coronavirus can be particularly dangerous in certain risk groups (advanced age, chronic disease, etc.) (7). In line with our findings, protective behaviors such as using masks could reduce anxiety (2). These concerns can also be mitigated by providing clear information to the public about threat risk, increasing the clarity of what they should do, and taking additional steps to protect vulnerable groups from the risk of infection (7, 18).
In a climate of uncertainty, it is expected that people will be worried about their health, relatives, the economy, and the effects of the pandemic on society. However, intense and dysfunctional concerns associated with COVID-19 negatively affect individuals’ mental health and should be considered therapeutic targets. In a study, Wahlund et al. (33) reported that online cognitive behavioral interventions targeting intensive and dysfunctional COVID-19-related concerns (e.g., illness, death, economy, family) are effective in reducing anxiety and improving mood, daily functioning, and intolerance to uncertainty. The findings of our study demonstrate the concerns about the pandemic that can be potential therapeutic targets and their significant adverse effects on mental health.
This study has some limitations. The collection of study data using an online tool may have made it difficult to access risky elderly individuals and those with low socioeconomic status, in particular. The lack of assessment of media exposure among individuals can be considered a limitation because worries about the pandemic may be affected by media exposures. However, the fact that individuals’ concerns about the adverse effects of the pandemic on the health system and socioeconomic conditions were investigated, and the scales validated in a normal clinical sample were used, could be mentioned as advantages.
CONCLUSION
During the pandemic, it is essential to take measures to protect individuals’ mental health. Individual worries about their health, relatives, economy, and the effects of the pandemic on society have significant adverse effects on mental health. Social and health policies should be planned to reduce individual concerns during the pandemic.
ACKNOWLEDGMENTS
We thank all the study participants who responded to our questions and gave their time to this study.
