key: cord-269245-bp4q4plt authors: Zhang, Yuan; Wang, Shu; Ding, Wei; Meng, Yao; Hu, Huiting; Liu, Zhenhua; Zeng, Xianwei; Guan, Yuguang; Wang, Minzhong title: Status and influential factors of anxiety depression and insomnia symptoms in the work resumption period of COVID-19 epidemic: A multicenter cross-sectional study date: 2020-09-18 journal: J Psychosom Res DOI: 10.1016/j.jpsychores.2020.110253 sha: doc_id: 269245 cord_uid: bp4q4plt Objective: In this study, the authors analyzed the status of anxiety depression and insomnia symptoms and influential factors in the work resumption period of Coronavirus disease 2019 (COVID-19). Methods: A multicenter cross-sectional survey was conducted from March 2, 2020 to March 8, 2020 in Shandong Province, China, using quota sampling combined with snowball sampling. The Generalized Anxiety Disorder-7 (GAD-7), the Patient Health Questionnaire-9 (PHQ-9), and the Insomnia Severity Index (ISI) were used to assess the anxiety, depression, and insomnia symptoms. The multivariate logistic regression analysis was used to explore the influential factors. Results: A total of 4000 invitations were sent from three centers, 3237 valid questionnaires were received. Based on GAD-7, PHQ-9, and ISI scales, 19.5%–21.7% of the participants had anxiety, depression, or insomnia symptoms; 2.9%–5.6% had severe symptoms. Besides, 2.4%, 4.8%, and 4.5% of the participants had anxiety-depression, anxiety-insomnia, or depression-insomnia combined symptoms. The scores of anxiety and insomnia symptoms, along with scores of depression and insomnia symptoms were positively correlated in these samples. Aged 50–64 years and outside activities once in ≥30 days were risk factors of anxiety, depression, and insomnia symptoms in common. During the epidemic, 17.4% of the participants had received psychological interventions, and only 5.2% had received individual interventions. Conclusions: The incidence of psychological distress increased during the outbreak of COVID-19 in the work resumption period than the normal period. Current psychological interventions were insufficient; target psychological interventions should be conducted in time. The outbreak of Coronavirus disease 2019 (COVID-19) became a global health threat in early 2020 [1, 2] . The COVID-19 was highly infectious and fatal to some patients [3] . So far, there was no specific remedy [4] . To control the spread of COVID-19, the Chinese government implemented a strict restriction on outdoor activities from the Spring Festival [5] . By the late February 2020, the epidemic was effectively controlled in mainland China [6] . On February 21, 2020, the State Council of the P.R.C. published a guideline for the prevention and control of COVID-19 during the work resumption period, which announced the permission of work resumption [7] . As the epidemic has not been completely resolved [8] , the work resumption procedure was gradually conducted and cross-regional activities were still restricted. The panic caused by the epidemic, the communication reduction caused by interpersonal isolation, and the economic impact caused by production suspension can trigger the stress response, which may induce psychological distress even mental illness [9] [10] [11] [12] [13] . Previous studies suggested that the Severe Acute Respiratory Syndrome (SARS), the Middle East Respiratory Syndrome (MERS), and the Ebola virus disease (Ebola) epidemics had serious psychological influences to a wide range of people [14] [15] [16] . It is necessary to conduct target psychological intervention timely and effectively to prevent psychological distress from worsening. Although previous studies conducted some investigations of the psychological status during the outbreak of COVID-19, there was limited analysis of the psychological status and influential factors in the work resumption period [10, 17, 18] , and this is a global research gap for COVID-19 research [19] . In the work resumption period, The present study consisted of a pre-investigation and a formal investigation. The pre-investigation was launched from February 24, 2020 (next week after the permission of work resumption [7] ) to February 26, 2020 . The objectives of the pre-investigation were to foster multicenter collaboration, to assess sampling procedure, to examine the accessibility of the questionnaire, and to determine the sample size of the formal investigation. The three collaboration centers sent a total of 450 invitations (150 for each center) and received 378 (84.0%) valid questionnaires. The proportion of participants with anxiety, depression, or insomnia symptoms was 19.2-21.0%. Based on the pre-investigation, the permissible error was set as 0.03 and the drop-out rate was set as 20.0%. The Clopper-Pearson formula for two-sided confidence intervals for one proportion was used to determine the sample size. After calculation in PASS software (NCSS LLC., Kaysville, Utah, USA; version 15), the desired dropout-inflated enrollment sample size was 3622. The number of invitations sent in the formal investigation was set as 4000. The official investigation was performed from March 2, 2020, to March 8, 2020. As cross-regional outside activities were still restricted, it was impossible to conduct a random sampling procedure by investigating from house to house. A population-based representative quota sampling method combined with a snowball sampling method was designed. First, the proportion of the population in each region was determined according to the census of Shandong Province (published in 2019, data as of the end of 2017) [21] . The quotas for invitations sent was based on the proportion of population in these three regions (western region (western center): n = 1300; middle region (middle center): n = 1400; eastern region (eastern center): n = 1300). Second, a cross-control quota sampling procedure for characteristics of the population (subregion, age, gender, occupation) in each region was conducted. Third, based on online unified questionnaire or a telephone survey (for people who cannot answer online, such as elderly; the content is consistent with the online questionnaires). All participants were required to answer only once through one review method. A detailed description of the similar sampling method has been published elsewhere [20] . Figure 2 shows the sampling process. The questionnaire consisted of three parts. The first part collected characteristics, (public, individual). The third part was standardized scales, including GAD-7, PHQ-9, and ISI, to assess anxiety, depression, and insomnia symptoms. Participants were required to respond based on the experiences of the past two weeks. The suitable classification standards of these three scales were determined by the Chinese consensus reviewed by psychologists. The GAD-7, PHQ-9, and ISI score ≥ 10, 10, 15 indicate anxiety, depression, and insomnia symptoms; scores ≥ 15, 15, 22 indicate severe anxiety, severe depression, and severe insomnia symptoms. For participants aged under 18, total scores ≥ 11 points in PHQ-9 is consider to have depression symptoms [27] . At the end of the questionnaire, a trust question was set as "did you answer truthfully". Questionnaires with "No" response in the trust question, the All statistical analyses were performed using the SPSS software package (IBM, Armonk, New York, USA; version 26). The influential factors of anxiety, depression and insomnia symptoms were analyzed by logistic regression. The division of ages was consistent with the Chinese epidemiology study of mental disorders by Huang et al. [28] in the normal period and the cross-sectional study of psychological status by Wang et al. [20] in the outbreak of COVID-19 to set as contracts. Variables showing a P-value of < 0.10 in the univariate analysis (Pearson x 2 or Fisher exact test) were then entered into a multivariate logistic regression analysis with a backward method. The OR value and its 95% confidence interval (95%CI) were given for independent factors, and the OR value > 1 indicated risk factors. Besides, after the GAD-7, PHQ-9, and ISI scores of the participants were tested for normality (Kolmogorov-Smirnov test), Pearson's correlation analysis was performed to explorer the correlation of scores. A P value of < 0.05 was considered statistically significant. Table 1 shows the participants' characteristics and experiences related to the COVID-19 epidemic. According to the GAD-7, PHQ-9, and ISI scales, 20.8% (674) Table 4. ). The wildly spread COVID-19 epidemic and strict interpersonal isolation can trigger stress response [29] . The occurrence of stressful life events is a risk factor for psychopathology, and environmental stressors also induce stable changes in gene expression within the brain that may lead to mental illnesses [30, 31] . Coming into the work resumption period, many factors can become stressors of a wide range of people in a comprehensive effect, including epidemical panic, interpersonal isolation, economic volatility, and resumption status. The present study revealed that resumption period than the normal period. An online survey [17] and another study on Chinese web users [18] suggested that one-third of people had anxiety symptoms during the outbreak of COVID-19 and the negative emotion increased. But they only focused on web users, which might limit their overall representation. A previous nationwide cross-sectional study of the research team was conducted from February 10, 2020 to February 17, 2020 (during the outbreak of COVID- 19) in China with a similar design of the present study. They proposed 12.2%, 11.0%, and 13.3% of the participants had anxiety, depression, or insomnia symptoms. The proportion of anxiety, depression, and insomnia symptoms got increased the present study [20] . Wang et al. Besides, the present study also showed that 2.4%, 4.8%, and 4.5% of participants had anxiety-depression, anxiety-insomnia, or depression-insomnia combined symptoms. The scores of anxiety and insomnia symptoms (r = 0.719), along with scores of depression and insomnia symptoms (r = 0.698) were positively correlated in these samples. Previous studies suggested that environmental stressors or physiological disease might cause the comorbidity of anxiety, depression, or insomnia, which could provide a great challenge in the diagnosis and intervention [32, 33] . The comorbidity of anxiety and depression could make psychological distress worse and reduce treatment response, which should be considered [34] . Sleep disturbance is a common manifestation of anxiety and depression. Insomnia has been identified as a predictor of multiple mental disorders and could increase the risk for psychopathology [35] . Efforts should be made to strengthen interventions for sleep problems such as cognitive behavior therapy and mindfulness-based therapy [36] . This study also analyzed the risk factors for anxiety, depression, and insomnia According to an epidemiological study of mental disorders, Chinese aged 50-64 years had a higher incidence of mental illness than the other age groups [28] , which may explain the higher prevalence of anxiety, depression, and insomnia symptoms in participants aged 50-64 years in the present study. Furthermore, in China, many middle-aged and elderly people are in leadership positions in companies and families. The economic stress caused by the epidemic and work resumption could influence their mental health [37] . Therefore, middle-aged and elderly people, especially aged 50-64 years, are easier to have psychological distress that needs interventions. In addition, the previous study of Wang et al. suggested participants aged 35-49 years had more severe anxiety, depression, and insomnia symptoms during the outbreak of COVID-19 [20] . This change in the high-risk age groups might be the combined influence of economic and epidemic pressure changes with time, which needs further exploration. Affected by the COVID-19 epidemic, a wide range of people reduced unnecessary outside activities and interpersonal communication, some of them even stayed home alone for a long time. In the present study, 15.0% of the participants had outside activities once in ≥ 30 days. Previous studies suggested that the interpersonal isolation of patients had a significant impact on mental health [38] . With further control of COVID-19, more and more people can restore interpersonal contacts and resume normal work in the future. The psychological distress may get released in some people. However, interpersonal isolation has a long-term influence on mental health, some people with psychological distress cannot relieve by himself, even after resuming interpersonal contacts [38] . Target psychological interventions should be performed in time to people under long-term interpersonal isolation before and after work resumption. In addition, several previous studies concerned the healthcare workers had a higher risk of psychological symptoms [12, 13, 20] . The present study did not find being frontline medical staff was a risk factor of psychological distress, which might relate to the effectively control of the epidemic, lower proportion of confirmed patients, higher proportion of accepting psychological interventions for these group, and higher proportion of recovering patients. However, more attention In the present study, only 17.4% of current participants had received psychological interventions, 5.2% had received individual psychological interventions during the outbreak of COVID-19. Compared with a previous study (1.9% received counseling during the outbreak) [20] , the proportion of people received psychological interventions got a great increase. But it was still insufficient for the potential proportion of people with psychological distress. The outbreak of COVID-19 limited face-to-face counseling and individualized psychological interventions, which was a serious challenge to the mental health service. Besides, there were still many people who did not pay enough attention to mental health [39] . Irvine et al. suggested that there was no significant difference between online or telephone psychological therapy and face-to-face psychological intervention in efficacy and detrimental effects [40] . Besides, community interventions by Internet or telephone and app-supported smartphone interventions also showed advantages in promoting mental health [41, 42] such as Internet-based cognitive behavior therapy [43] . However, some studies concerned that non-face-to-face psychological interventions might have defects in reliability and individualized treatment [40, 44] . We suggest that under the current circumstances, individualized psychological interventions are still important for high-risk groups, and the others should adopt public psychological education. As the outbreak of COVID-19 has not been completely resolved, online or telephone interventions can be chosen as preferred. When the epidemic is under control, individualized face-to-face psychological interventions should be resumed in time to Adjusted for all other variables. PHQ-9: the Patient Health Questionnaire-9; * P < 0.05 (Multivariate logistic regression); ** P < 0.01 (Multivariate logistic regression). Adjusted for all other variables. ISI: the Insomnia Severity Index; * P < 0.05 (Multivariate logistic regression); ** P < 0.01 (Multivariate logistic regression). 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