key: cord-0706494-sywnblvj authors: Hamama-Raz, Yaira; Goodwin, Robin; Leshem, Elazar; Ben-Ezra, Menachem title: The toll of a second lockdown: A longitudinal study date: 2021-11-01 journal: J Affect Disord DOI: 10.1016/j.jad.2021.06.080 sha: 7a6d1acaf140e90e4aa8e29281ef21f19e511f63 doc_id: 706494 cord_uid: sywnblvj Background The mental health toll of a second lockdown during the COVID-19 pandemic has not been yet examined. The purpose of the study was to examine psychological predictors before the second lockdown and their impact on the prediction of ICD-11 probable Adjustment Disorder (AjD) after the second lockdown. Methods Using a longitudinal design we surveyed a national representative sample of the Israeli population before and after the second lockdown. In wave 1, 1029 were surveyed (Response Rate (RR) = 76.17%) and in Wave 2, 764 were surveyed (RR = 74.24%). Participants answer a questionnaire tapping COVID-19 stressful related events, uncertainty, probable depression predicting ICD-11 and probable AjD. Results The main predictors of AjD after the second lockdown were sex (OR = 1.868; p ≤0.01), having a COVID-19 occupational related stressful event (OR = 2.855; p <0.001), probable depression (OR = 2.520; p <0.001) and Uncertainty (OR = 4.485; p <0.001). Limitations We recognise the limitations of response bias. In addition, we did not measure pre COVID-19 mental health. Conclusions The study results show the mental toll of a second lockdown during the COVID-19 pandemic. Lockdown plays an important role in helping prevent outbreaks of COVID-19 (Atalan, 2020) . Full lockdowns decrease the risk of biological threat and are positively associated with patient recovery (Chaudhry, and Maity, 2020) . Those countries that rapidly applied lockdowns reported reduced deaths compared to countries that delayed the application of this containment (Balmford and colleagues, 2020) . Nevertheless, lockdown has also been found to have direct, long lasting consequences for mental health and health-related behaviours (Niedzwiedz et al., 2020) . Multiple strains associated with lockdown, including health-related and work-related stressors, can increase the prevalence of adjustment disorder. In ICD-11, adjustment disorder (AjD) is recognized as a stressresponse syndrome. The symptom profile of AjD in ICD-11 is defined via two symptom categories: (1) excessive worry, distressing thoughts and rumination related to a stressor, and (2) significant impairment in major social, family or occupational life (Zelviene, and Kazlauskas, 2018) . Additionally, research suggests that intolerance of uncertainty (IU) may play a central role in the aetiology and maintenance of worry and rumination, which may explain its transdiagnostic associations with a variety of psychological disorders (Yook et al., 2020) . IU has been found to be a risk factor for depression and anxiety (Glowacz & Schmits, 2020) but has yet to be studied in the context of stress related disorders, such as AjD. The Israeli government applied two lockdowns following the first diagnosis of COVID-19 in Israel (21, February 2020). The first lockdown was between March 14 th to April 19 th 2020, the second five months later (September 18 th to November 8 th ). Using a longitudinal design, the current study explored associations between background variables, stress-related events, intolerance of uncertainty (IU) and probable depression just before the second lockdown (Time 1) and its association with AjD at Time 2 (just after the second lockdown). We used the Israeli iPanel company to deploy a COVID-19 Mental Health Survey. The panel is a probability-based panel with 100,000 members designed to be representative of the adult population in Israel. Data were collected from August 3 to August 30, 2020 for the first wave and November 15 th to December 3 rd for the second wave. The sample was administered online, and all participants signed an electronic informed consent. The study was approved by Ariel University Institutional Review Board (AU-SOC-YHR-20200616). In the first wave, out of 1351 invitations sent, 1029 responded (response rate = 76.17%); in the second wave, out of 1029 participants in baseline, 764 responded (response rate = 74.24%). We conducted a-priory sensitivity analyses for each wave targeting the demographic variables of age, sex, relationship status. No significant differences were found between those who answered the survey and those who did not in both waves. The sample mean age was 40.75 (SD = 14.75; range 18-71) with responses from 520 (50.5%) women. 600 participants (58.3%) were in a committed relationship. Participants completed the following self-report questionnaires: COVID-19 occupational stressful event was measured by the question: "Following COVID-19 pandemic, have you lost your job, been fired or furloughed" (Yes/ No). COVID-19 health related stressful event was indicated by the question: "Following COVID-19 pandemic, has your health deteriorated or were you diagnosed with a new illness, injury of disability (Yes/ No). Depression was measured using the Patient Health Questionnaire-9 (PHQ-9) (Kroenke et al., 2001) ; α was .88. Intolerance of uncertainty was assessed through the Intolerance of Uncertainty Scale (IUS-12) (Carleton et al., 2007) ; α was 0.91. The predicted variable was probable Adjustment Disorder (AjD) based on the ICD-11, post-lockdown. AjD was measured by the International Adjustment Disorder Questionnaire (IADQ) (Shevlin et al., 2020) ; α was .94. Table 1 presents descriptive statistics and correlations for the study variables. The results showed that COVID-19 occupational related problems, female sex, COVID-19 health related problems, intolerance uncertainty and having probable depression positively correlated with AjD post lockdown. The analytic plan used a logistic regression with the outcome variable ICD-11 probable AjD (Time 1). The predictors variables at Time 1 were: age, sex, relationship status, COVID-19 occupational problems, intolerance uncertainty and probable depression (PHQ-9 cut-off ≥10). The results showed that AjD before lockdown was predicted by female sex (OR = 2. This study provides new insights into the impact of lockdown following COVID-19, with a focus on the incidence of adjustment disorder. Our results are consistent with recent Lithuanian findings associating work and health-related stressors and AjD (Shevlin et al., 2020) . This suggests lockdowns, alongside the other stressors associated with a novel zoonotic threat such as COVID-19, should be treated as life stressors experience that might cause stress-related disorders, especially among those who suffer from occupational and health problems as a result of the lockdown. In addition, the associations between depression symptoms and AjD emphasise the importance of treatments targeted towards potential vulnerable groups, such as females and individuals with pre-existing mental health difficulties. As AjD has been associated with higher suicide risk (Casey et al., 2015) , governments and health care providers need to consider the consequences of applying several lockdowns when responding to future COVID-19 outbreaks, carefully balancing the reduction in infection vs. the risk of exacerbating economic difficulties and worsening mental health. Czeisler et al. (2020) revealed that younger adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers reported having experienced elevated suicidal ideation associated with COVID-19. During lockdown in Austria, Carlin and colleagues (2021) showd an increase in attempted suicides during the lockdown period. Given the above, E-health interventions such as the Brief Adjustment Disorder Intervention (BADI) for the treatment of ICD-11 adjustment disorder (Eimontas et al., 2018) , and Skills for Life Adjustment and Resilience (SOLAR) (O'Donnell et al., 2019) , might lessen the incidence of AjD following lockdown. We recognize possible response bias introduced by (Tables 2 and 3 ) participation through an online application. In addition, we did not have pre COVID-19 assessments of mental health condition, suggesting caution when interpreting the present findings. In summary, our findings indicate that the application of lockdowns to tackle novel zoonotic threats (such as COVID-19) can potentially induce significant psychological work-related and health-related stress, and depression, which in turn may result in AjD. Care must be taken when applying additional lockdowns to address the risk of further adjustment disorders. Prof. Hamama-Raz, Prof. Goodwin and Prof. Ben-Ezra have conceptualized the study. Prof. Hamama-Raz & Prof. Leshem acquired the data. Prof. Hamama-Raz, Prof. Leshem, Prof. Ben-Ezra analysed the data. Prof. Hamama-Raz, Prof. Goodwin and Prof. Ben-Ezra interpreted the data. Prof. Hamama-Raz and Prof. Ben-Ezra drafted the paper. Prof. Goodwin and Prof. Leshem revised it critically for important intellectual content. All author approved the final version of the manuscript. Prof. Hamama-Raz was supported by an internal grant from Ariel University (RA2000000302) The authors declare that they have no conflict of interest. Is the lockdown important to prevent the COVID-9 pandemic? 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