key: cord-0851723-z6ek7jbg authors: Cansel, Neslihan; Ucuz, İlknur; Arslan, Ahmet Kadir; Kayhan Tetik, Burcu; Colak, Cemil; Melez, Şahide Nur İpek; Şule Gümüstakım, Raziye; Ceylan, Sinem; Zeren Öztürk, Güzin; Kılıç Öztürk, Yasemin; Cadırcı, Dursun; Semra Demir Akca, Ayse title: Prevalence and predictors of psychological response during immediate COVID‐19 pandemic date: 2021-01-23 journal: Int J Clin Pract DOI: 10.1111/ijcp.13996 sha: 83ef7ea6758411ac18d1007827ff95695c103a17 doc_id: 851723 cord_uid: z6ek7jbg AIM: COVID‐19 pandemic has created a serious psychological impact worldwide since it has been declared. This study aims to investigate the level of psychological impacts of the COVID‐19 pandemic on the Turkish population and to determine related factors. METHODS: The study was carried out by an online questionnaire using the virtual snowball sampling method. The sociodemographic data were collected on the following subjects: participants’ experience on any signs of infection within the last month, the history of COVID‐19 contact‐treatment‐quarantine, level of compliance with precautionary measures, the sources of information and level of knowledge about the pandemic process and their belief levels on the knowledge they acquire. Besides, the questions that take place in the Depression, Anxiety and Stress Scale‐21 (DASS‐21), and Impact of Events Scale‐Revised (IES‐R) were asked to participants. RESULTS: Of the 3549 participants, anxiety was found in 15.8%, depression in 22.6%, stress in 12.9%, and psychological trauma in 20.29% based on moderate and above levels. Female gender, young age, higher education level, being single, high monthly income, presence of psychiatric illness, a large number of people living together, having any signs of infection, and contact history with COVID‐19 infected person or contaminated object are identified as risk factors that may increase psychological impact. Compliance with the rules was found to reduce the risk of psychological response. CONCLUSIONS: The risk factors for the psychological impact of the COVID‐19 pandemic, and acknowledging these factors can help to formulate the interventions to reduce the stress levels of the population. more than 200 countries worldwide and has affected thousands of people since its inception. The number of reported cases increases every day and by this time (09.12.2020) throughout the world the number of confirmed cases has reached the number of 67.530.912 and 1.545.140 people died. 3 The outbreak not only increased the risk of death from a viral infection but also caused people to experience unbearable psychological pressures. 4 Before the declaration of any confirmed cases in Turkey, images, and videos which were spread via social media and TV news have created a panic in Turkey as well as all over the world. Many factors such as the persistence of the pandemic in the world, the lack of current treatment, and the uncertainty of the duration of the measures taken brought forward the risk of being affected psychologically. As a matter of fact, recent studies have shown that struggling with this uncertainty as well as the physical effect of the disease, economic-educational losses, etc, because of social isolation, may decrease the communication amongst people and increase the rates of depression and anxiety over time. [4] [5] [6] [7] Naturally, in an extraordinary situation such as pandemic, acute psychological exposure may be a foregone conclusion, but continuing the process may cause permanent psychological and biological effects. Therefore, while evaluating the pandemic, the detection of psychological problems, and related factors that may develop; it is important to determine the target audience, to take the necessary precautions, and to direct the aid. In the light of this information, in this study, it is aimed to determine the level of psychological impact and the factors that may be related to the COVID-19 outbreak in Turkish society where precautionary measures were implemented in the 6th week of the pandemic in the country. This study is a cross-sectional study and has been approved by the ethics committee (2020/652). This study was conducted 6 weeks after the first COVID-19 case was officially announced. The individuals who were planned to participate in the study were determined by a virtual snowball sampling method and invited to participate in the web survey online. Data acquisition was stopped when the targeted sample size of 3549 people was reached within 5 consecutive days. A questionnaire consisting of seven sub-units was sent to the participants. Section 1 of the questionnaire included sociodemographic features, Section 2 included questions on the presence of symptoms for any infectious disease, contact with COVID-19, treatment, quarantine history, Section 3 included questions on compliance with the measures taken (these questions were inspired by the 14 rules determined by the official authorities in our country), Section 4 included questions on the source from which information about COVID-19 was acquired; level of knowledge, belief in the information received, health services and measures sufficiency level, level of belief in life chances. Section 5 included questions on anxiety associated with possible health and sociological losses of the pandemic. The 6th section consisted of DASS-21 related questions and Section 7 consists of questions related to IES-R. DASS and IESR were used in previous pandemic studies. 8, 9 Data for individuals 18 and older who agree to participate voluntarily were included in the current study. Data of What is known? The COVID-19 pandemic caused various problems related to viral infection, including the risk of death. 2. In addition, it caused different levels of psychological effects in individuals. 1. Risk factors causing psychological response such as sociodemographic variables, data on the areas of concern, the level of compliance with precautionary measures, the participants' information source, the presence of physical symptoms, were determined in detail within the same study. 3. Compliance with the rules was found to reduce the risk of psychological response. individuals with a history of bipolar disorder and/or psychotic disorder were not evaluated and excluded during the analysis phase. In the study, DASS-21 was used to evaluate the current mental impact. DASS-21 is a short-form version of the original 42-item questionnaire designed as self-report. 10 Its validity and reliability in Turkish were performed by Sarıçam in 2018. 11 The scale consists of depression, anxiety, and stress subfields. In the depression subscale, 0-4 points are normal, 5-6 points are mild, 7-10 points are moderate, 11-13 points are severe, and ≥14 points are extremely severe. In the anxiety subscale, 0-3 points are normal; 4-5 points are mild, 6-7 points are moderate, 8-9 points are severe, ≥10 points are extremely severe anxiety; in the stress subscale, 0-7 points are normal, 7-8 points are mild, 10-12 points are moderate, 13-16 points are severe, and ≥17 express extremely severe stress. The scale which was originally named Impact of Event Scale-Revised (IES-R) 12 was used to measure the psychological trauma caused by the COVID-19 outbreak in the study. The Turkish validity and reliability of this scale, which is widely used in daily clinical practice and studies to evaluate the severity of post-traumatic stress, was made by Çorapçıoğlu et al in 2016. 13 There are 22 questions divided into three subgroups (intrusive, avoidance, hyperarousal) on the scale where the severity of symptoms in the last 7 days is scored between 0 and 4. For the total IESR score, 0-23 is normal, 24-32 mild, 33-36 moderate, and ≥37 indicate severe psychological impact. The quantitative data used in the study were summarised as arithmetic mean ± standard deviation and qualitative data as numbers (percent). As the four dependent variables in the study, DASS-21 anxiety, depression and stress subfields, and IES-R total scores were selected, and the related data were converted into binary categorical data according to the following criteria. A cut-off of the IES-R total score ≥33 was used to reflect moderate-to-severe impact. 14 Similarly, individuals with a score of 7 and above in the depression subscale, 6 and above in the anxiety subscale, 10 or above in the stress subscale cut-off points were used to determine the moderate and above psychological influence reflected on DASS-21. 8 Since the number of dependent variables is four, four different binary logistic regression models were applied to the data set. Before applying the related models, variable selection algorithms based on each dependent variable were applied to the data, and independent variables considered to have no contribution to modelling were removed from the data set. As a variable selection method, LASSO (Least absolute shrinkage and selection operator) 15 logistic regression technique was applied. The goodness of fit and coefficients of the created models were evaluated by Hosmer-Lemeshow (P > .05) and Omnibus (P < .05) tests, respectively. In logistic regression models, the significance level for model coefficients was determined as P < .05. In the analysis, "BKSY: Information Discovery Process Software" developed by Inonu University Faculty of Medicine Department of Biostatistics and Medical Informatics was used for the data analysis. 16 The data obtained from 3549 people were included in the research. Data related to the relationship between sociodemographic variables and DASS-21 and IES-R are given in Table 1 . Increasing age was associated with high depression (P = .021, OR = 0.985) and stress (P = .015, OR = 0.981) scores, but had no effect on anxiety and IES-R scores (P > .05). Being a woman generated more risk for anxiety, depression, and stress and trauma response. According Data related to the participants' history of contact and treatment with COVID-19 within the last month and their psychological response levels are shown in Table 2 The relationships between the presence of physical symptoms and psychological responses in the last 1 month are given in Table 3 . When the participants were questioned whether they had experienced any / several of the symptoms of fever, cough, sore throat, shortness of breath, chest pain, headache, runny nose, muscle pain, diarrhoea, nausea in the past 1 month. In the analysis, different symptoms caused different levels of psychological response. The presence of fever in the last 1 month had an enhancing effect on the development of anxiety (P < .001, OR = 2.193) and stress (P = .013, OR = 1.572). Sore throat was associated with high anxiety and IES-R (P = .049, OR 1.282, P = .016, OR = 1.431, respectively). Chest pain had an effect on increasing the risk for anxiety (P < .001, The relationships between the sources of information, its level, belief in knowledge, and psychological response are given in Table 4 . One thousand seven hundred ninety-seven (50.6%) participants stated that they received information about COVID-19 most frequently from TV/radio. When the participants are evaluated in terms of knowledge level, source, and belief level from which the information is obtained; these variables had no effect on psychological The relationships between the compliance level of the participants and the psychological response are given in Other The relationships between the areas of concern and the level of psychological response are given in Table 6 . Considering the dis- This study provides important data regarding the impact of the pandemic in Turkey. First of all, it was detected that the society was significantly affected by the pandemic. Amongst the participants in the study; based on moderate and above psychological effects, anxiety was found in 15.8%, depression in 22.6%, stress in 12.9% for Other The relationship between the data on areas of concern and psychological response levels Reference category Other were also factors that increased the risk of psychological response in individuals. This result seems to be a reflection of the anxiety developed in accordance with the nature of "uncertainty." In the literature, "uncertainty" is accepted as causing a series of cognitive, emotional, and behavioural damage in the process of time. It is also considered as a "basic component of all anxiety disorders" which reduces problem-solving ability. 32 Accordingly, taking precautions such as regular sharing of information that will eliminate this uncertainty during the days of pandemic intensification, dissemination of diagnostic tests can contribute positively to the mental health of the society. According to previous studies, despite social differences, there is a relationship between compliance with the measures taken and psychological impact. 23 In the study of Wang et al, compliance with precautionary measures has been shown to reduce the psychological response. 8 In our study which is consistent with the literature, it was found that the majority of the participants to be complying with the measures taken although Turkish society has been facing such a pandemic for the first time in its history. It has been also remarkable that people's adaptation to the rules to have a positive effect on psychological response. It is an expected result for a society in which people state that they pay more attention to the health of their relatives rather than their own and that they do not feel psychologically uncomfortable. In addition, it has been observed that regular exercise, a balanced diet, and attention to sleep patterns are protective factors in psychological response. However, it was found that most of the participants complied with these measures at a lower rate. Therefore, raising awareness of the society for these measures which are effective in psychological and biological empowerment seems to provide significant benefits in combating pandemics. When the areas where the participants are concerned are evaluated, similar to previous pandemic studies, 33 the first three places, respectively, were the health of family and relatives, anxiety to infect others, and going to health controls. However, it was seen that the characteristics of the individuals during the pandemic caused anxiety about different issues. For example, academic anxiety was the primary concern amongst young people aged 18-25. The individuals with the most economic concerns were those with a monthly income of 2500-5000 TL and university graduates. A remarkable result here was that people's anxiety about taking medications that they had to take constantly increased their stress levels by 75.5%. Biologically at risk of further damage than COVID-19 34 this anxiety of the people is an important situation in terms of the disruption of the treatments and subsequent serious health problems. Unfortunately, our study on why people bear this concern has not been able to provide a clear explanation. However, in our opinion, presenting information that has not been confirmed about whether or not some drugs can be taken in the media seems to cause more confusion and anxiety. Therefore, preventing information pollution about COVID-19 and making necessary explanations to these people at risk, will contribute to the reduction of anxiety levels, and it seems to contribute positively to the lives of these people with physical illness. For that purpose, the presentation of online or smartphone-based psychoeducation applications, which include cognitive behavioural therapy (CBT) and mindfulness-based cognitive therapy can be helpful to provide correct information to these people who have exaggerated fear. Especially in this period of intense transmission, these may correct their cognitive biases and help them to improve their ability to manage and cope with their anxiety by relaxation techniques. 35, 36 Moreover, digital CBT, which covers a range of technologies such as the internet, smartphone applications, and other devices such as computers, can reduce this transmission from face-to-face communication and therapy. Since it provides easier access and has lower cost, 36, 37 not only the workload of hospitals would be reduced but also economic contribution can be succeeded. Furthermore, these platforms can also provide a support network for those people who have to spend most of their time at home during the pandemic. 8 There were some limitations regarding this study. First, although this study has reached a relatively high sample size from different strata of the society, inviting participants to the study in an electronic environment has prevented those who do not have this opportunity and those who do not read or speak Turkish. Therefore, the results may not reflect the general population. Additionally, this study mainly used self-reported questionnaires to measure psychiatric symptoms and did not make a clinical diagnosis. The gold standard for establishing psychiatric diagnosis includes a structured clinical interview and functional neuroimaging. 38, 39 In the future, the information obtained through face to face interviews and particularly functional neuroimaging rather than a questionnaire will correct the limitations. Second, because of the cross-sectional type of research, its place in the determination of psychological effects in the long term is limited. This indicates that follow-up studies are needed to determine the long-term effects of the pandemic. Despite all these limitations, our study provides important data in terms of determining the changes in the mental health of society and related factors. These outcomes can guide in determining and directing the measures to be taken now and in the future. COVID-19: knowns, unknowns, and questions SARS and MERS: recent insights into emerging coronaviruses World Health Organization. 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