key: cord-0720734-65k6fhct authors: García-Fernández, Lorena; Romero-Ferreiro, Verónica; López-Roldán, Pedro David; Padilla, Sergio; Rodriguez-Jimenez, Roberto title: Mental health in elderly Spanish people in times of COVID-19 outbreak date: 2020-07-07 journal: Am J Geriatr Psychiatry DOI: 10.1016/j.jagp.2020.06.027 sha: 4436187b62e963dd02a119414752fbe786cfd066 doc_id: 720734 cord_uid: 65k6fhct BACKGROUND: We aim to assess COVID-19 outbreak-related emotional symptoms, identify gender differences, and study the relationship between the emotional state and environmental features in the elderly. METHODS: We conducted a cross-sectional study starting on March 29 to April 5, 2020 based on a national online survey using snowball sampling techniques. Symptoms of anxiety (Hamilton Anxiety Scale), depression (Beck Depression Inventory) and acute stress (Acute Stress Disorder Inventory) were compared between people over and under 60 years old. Gender differences and the relationship of loneliness, regular exercise, economic losses and use of anxiolytics on the mental state were evaluated. RESULTS: 1639 [150 (9.2%) aged ≥60] participants completed the survey. The ≥60 group showed lower mean (SD) BDI levels than the <60 group [3.02 (3.28) vs. 4.30 (4.93)]; and lower mean (SD) ASDI scores than the <60 group [3.68 (3.20) vs. 4.45 (3.06)]. There were no gender differences in any of the clinical measures. The presence of economic losses as well as the increase in the use of anxiolytics was significantly associated with higher emotional distress in the elderly compared to the younger group. CONCLUSIONS: Older people has shown less emotional distress, with no differences between men and women. Economic loss and substance use should be monitored to guarantee the emotional well-being of the elderly. Several months have passed since the first cases of pneumonia caused by a new viral agent called severe acute respiratory coronavirus 2 (SARS-CoV-2) were reported in the Chinese city of Wuhan (1, 2) . The rapid increase in the number of contagions (3) Research focused on COVID-19 and also in previous pandemics has identified negative consequences for the mental health of general population (6) (7) (8) . Therefore, in a wide number of countries including Spain the impact of this abrupt and novel situation on mental health, both in general population and on those most vulnerable such as older adults (9) more prone to infection, severe illness and death (10) , is being studied (11, 12) . During this unprecedented pandemic, the entire population has been forced to suffer a physical risk and an impaired of emotional well-being, but the elderly has undoubtedly been one of the most vulnerable groups. The WHO states that in many countries, older people are facing the most threats and challenges from COVID-19 as they are in higher risk of developing severe illness (12) (13) (14) (15) , with a fatality rate of 3.6% among 60-69 years old, which increases to 18% above 80 years (16) (17) . Moreover, the aged have an added stress as they are aware of the greater severity and fatality among other population groups, registering in Spain the highest number of deaths (18) . People over 60 years of age represent 26% of the total Spanish population, they comprise 55% of all cases and more than two thirds of all deaths related to . In addition, the social consequences of quarantine must also be taken into account. Social disconnection is especially important for this age group less used to digital technologies as it may limit social engagement, interfere with daily routines, enhance inactivity, increase drugs use and decrease sensory stimulation. All these circumstances together with isolation might have an adverse impact on mental health of the elderly population. Given the established association between increasing age and poor prognosis in COVID-19 it would be wise to hypothesize that emotional distress would evolve in the same way placing the elderly in a situation of vulnerability to the virus, as well as to the psychological effects of the pandemic and the quarantine. However, there is little information about the impact of the new COVID-19 pandemic on mental health in the elderly outside China (19) (20) (21) . Preliminary research is scarce and contradictory as there are studies showing an increased incidence of psychological distress in the elderly (22) and others not reporting a higher prevalence of depressive symptoms in the older age Chinese population (11) . Thus, the aim of the current study is to evaluate the impact of the new COVID-19 pandemic on the mental health of people over 60 compared to those under 60 years old, find out if there are gender differences in anxiety, depression and acute stress in the elderly, and finally, evaluate the relationship that some environmental variables as loneliness, regular exercise, economic losses and use of anxiolytics have on the mental state. A total of 150 responders over or equal 60 years old (≥60) and 1489 under 60 years old (<60) participants compose this cross-sectional study based on a national online survey previously published by our group (23) . The questionnaire was administered applying an exponential nondiscriminative snowball sampling used in similar studies (11, 24, 25) . As part of the circulation strategy, the questionnaire was published on the hospital website, advertised in the local media and distributed by social networks to different geographic regions in Spain. Up to 2710 participants completed the self-reported online questionnaire from March 29, 2020, to April 5, 2020, which covers the peak of the SARS-CoV-2 infection in Spain. For the purposes of the present study, healthcare workers (n = 866) were not included as they constitute a special study subgroup and having a current or past mental illness reported (n = 205) was considered an exclusion criterion. Informed consent was provided by all survey participants. The survey was anonymous, and confidentiality of information was assured. The study was approved by the local clinical research ethics committee. Sociodemographic information on age, gender and occupation was required in the survey. In addition, loneliness, regular practice of exercise, income loss and increased consumption of anxiolytic substances were included. In order to assess symptoms of anxiety and depression, we included questions from the Hamilton Anxiety Scale (26) (HARS) and from the Beck Depression Inventory (27) (BDI) respectively. For reporting the presence of acute stress, we adapted ad hoc for this study the clinical criteria for the diagnosis of Acute Stress Disorder (Acute stress disorder inventory -ASDI-) of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (28). We developed a list of symptoms to be applied as self-reported questionnaire with dichotomous answer (yes/no). ≥60 and <60 comparisons on sociodemographic and clinical variables were done using analysis of variance corrected for age and gender and chi-squared tests as appropriate. Then, we analysed differences in gender among ≥60 participants using a Student's t test. We further explored the relationship of loneliness, regular practice of exercise, income loss and increased consumption of anxiolytic substances on anxiety, depression and acute stress (HARS, BDI and ASDI scores) within the group of aged responders using ANCOVA adjusted for gender. The study sample consists of 58.7% of women in ≥60 and 69.2% in the <60 participants with significant differences between groups (χ 2 (1) = 6.39, p= .01). Regarding anxiety symptoms, ANCOVA corrected for gender did not show significant differences between participants aged ≥60 and <60 (F ( Using Student's t test, we found no differences between males and females score in any of the Table 1 . The current study has aimed to measure the impact of COVID-19 on mental health of the elderly in Spain. Overall, results show that those above 60 are less vulnerable than younger participants to suffer from depression and acute stress, furthermore, they have not shown Little is known about the state of elderly mental health during the COVID-19 outbreak and data addressing the impact of previous epidemics in this age group are also scarce 29 because older patients have been usually excluded from clinical trials (30) . The few Chinese existing studies identify groups of ages between 18 and 30 and those over 60 years old as higher risk populations for stress reactions (22) , without observing higher rates of depression in the latter (11) . Without a doubt, the elderly population has been the most punished, reaching a worrying high death rate in nursing homes due to the COVID-19 or compatible symptoms since the beginning of the outbreak. For this reason, it is necessary to investigate plausible explanations for this unexpected result. A possible hypothesis could be that the elderly in Spain had a greater resilience than the younger. Thus, the Spanish elderly could have experienced more personal difficulties throughout their lives than non-elderly people, such as economic and social difficulties associated with the Spanish post-civil war period , which could have increased their ability to cope with the stress caused by the nowadays pandemic. Finally, regarding to the studied environmental variables, the results have shown that unlike what has been seen in situations of isolation and social distancing due to different circumstances (31), our data do not show a relationship between loneliness and the increase in anxiety, depression and acute stress. In the same line, neither a significant relationship between the absence of regular physical exercise and emotional symptoms has been found, contrary to what was expected (32) . However, economic losses do significantly increase emotional distress in this group of people, sensitive to the economic fallout (33) . About 4% of the variance of anxiety scores, 3% of depressive scores and 7% of the ASDI scores are associated with economic losses. Furthermore, an increase in the use of anxiolytic substances, alcohol or other drugs has been observed in those over 60 with higher levels of anxiety, depression and acute stress, probably with a relaxing purpose as a self-medication (34, 35) . About 14% of anxiety scores, 17% of depressive scores and 15% of ASDI scores are associated with anxiolytic intake. Results of this study should be interpreted in light of several limitations. First, response bias exist as a voluntary online self-administered survey was applied using a snowball sampling method; and second, the study was not specifically designed for the elderly, thus only general environmental variables have been queried. Strengths include data collection in a great sample during the height of the pandemic in Spain and the incorporation of a broad representation of the general population without any current or previous mental disorder. To the best of our knowledge, this is the first time that symptoms of anxiety, depression and acute stress affecting the elderly in a critical period of COVID-19 is studied in a western country like Spain, compared with a group of non-elderly individuals. The elderly sample has shown less emotional distress, with no differences between men and women. In addition, loneliness as part of the isolation imposed by quarantine has not been associated with the negative psychological consequences that usually accompany social disconnection in circumstances other than the current pandemic. Finally, it would be convenient to particularly assess the emotional state of the elderly living in nursing homes where the death rate has been high and to establish strategies to guarantee the economic security of the elderly, as well as to monitor and prevent the development of substance use disorders in order to guarantee their emotional well-being. This research received no specific grant from any funding agency, commercial or not-for-profit sectors. It is essential to know the impact of the new COVID-19 pandemic on the mental health of the elderly. 2) What is the main finding of this study? Older participants have shown less emotional distress than younger participants, with no differences between men and women. Moreover, the economic losses and the increase in the use of anxiolytics have been related to higher levels of anxiety, depression and acute stress in the elderly. 3) What is the meaning of the finding? It seems convenient to establish strategies to guarantee the economic security of the elderly, as well as to prevent the development of substance use disorders. A novel coronavirus from patients with pneumonia in China A new coronavirus associated with human respiratory disease in China Nowcasting and forecasting the potential domestic and international spread of the 2019-nCoV outbreak originating in Wuhan, China: a modelling study Global influenza strategy 2019-2030 Real Decreto 463/2020, por el que se declara el estado de alarma para la gestión de la situación de crisis sanitaria ocasionada por el COVID-19. Ministerio de la Presidencia The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak Psychosocial impact among the public of the severe acute respiratory syndrome epidemic in Taiwan Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science Preventing and Controlling Measures of 2019 Coronavirus Disease (COVID-19): Practice in Psychogeriatric Ward. The American journal of geriatric psychiatry: official journal of the American Association for Geriatric Psychiatry Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China Public responses to the novel 2019 Japan: Mental health consequences and target populations Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study Clinical Characteristics of 138 Hospitalized Patients with Novel Coronavirus-Infected Pneumonia in Wuhan, China Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): The epidemic and the challenges The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak Spanish Ministry of Health. Health alert and Emergency Coordination centre Government of Spain COVID-19 and the consequences of isolating the elderly Mental health services for older adults in China during the COVID-19 outbreak Ageing and COVID-19: What is the Role for Elderly People? A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations Mental health impact of COVID-19 pandemic on Spanish healthcare workers Study of knowledge, attitude, anxiety & perceived mental healthcare need in Indian population during COVID-19 pandemic The experiences of health-care providers during the COVID-19 crisis in China: a qualitative study. The Lancet Global Health The assessment of anxiety states by rating Rating scales for mood disorders: applicability, consistency, and construct validity American Psychiatric Association, & American Psychiatric Association Geriatric mental health and COVID-19: An eyeopener to the situation of the Arab countries in the Middle East and North Africa Region COVID-19 in Older People: A Rapid Clinical Review Loneliness is adversely associated with physical and mental health and lifestyle factors: Results from a Swiss national survey The effects of physical activity on anxiety, depression, and quality of life in elderly people living in the community Effect of COVID-19 on the mental health care of older people in Canada Self-medication of anxiety disorders with alcohol and drugs: Results from a nationally representative sample Mental health for older adults and benzodiazpine use We thank all participants who have kindly responded to the survey.