key: cord-0870581-d9jwy5b6
authors: Duan, Hongxia; Yan, Linlin; Ding, Xu; Gan, Yiqun; Kohn, Nils; Wu, Jianhui
title: Impact of the COVID-19 pandemic on mental health in the general Chinese population: Changes, predictors and psychosocial correlates
date: 2020-08-18
journal: Psychiatry Res
DOI: 10.1016/j.psychres.2020.113396
sha: 945c45d4310ed20c5d9a92007c08850f80f88053
doc_id: 870581
cord_uid: d9jwy5b6

The current COVID-19 pandemic is not only a threat to physical health, but also brings a burden to mental health in the general Chinese population. However, the temporal change of mental health status due to pandemic-related stress in relation to protective and risk factors to hostility is less known. This study was implemented at two timepoints, i.e., during the peak and the remission of the COVID-19 pandemic. 3233 Chinese individuals participated in the first wave, and among them 1390 participants were followed in a second wave. The result showed that fear significantly decreased over time, while depression level significantly increased during the second wave compared to the first wave of the survey. Younger age, lower-income, increased level of perceived stress, and current quarantine experience were significant predictors of depression escalation. Younger people and individuals who had a higher initial stress response tended to show more hostility. Furthermore, the use of negative coping strategy plays a potential intermediating role in the stress-related increase in hostility, while social support acts as a buffer in hostility in the general population under high stress. As the whole world is facing the same pandemic, this research provides several implications for public mental health intervention.

Since December of 2019, China has experienced a dramatic outbreak of a novel coronavirus disease 2019 (COVID- 19) , which rapidly spread in China and abroad.

Wuhan, the center city of the epidemic, was locked down for 76 days from January 23 to April 8, and many other regions in China initiated first-level responses to major public health emergencies to curtail further disease transmission. Since the announcement of global pandemic threat by the World Health Organization (WHO) on March 11, 2020, many other countries initiated their lockdowns on their own. Only one study explored the change of mental health problem from the initial outbreak phase (end of January) to the epidemic's peak or acute phase (end of February) in the general public (n = 333) (Wang et al., 2020b) . However, they could not investigate the temporal change of mental health problems at the individual level because they were not able to identify repeated respondents at the second time interval.

A commonly reported phenomenon in the media during this pandemic is an increase in hostility against people from such as medical profession, other nations or domestic ethnic minorities around the world (Wikipedia: List of incidents of xenophobia and racism related to the COVID-19 pandemic). In laboratory studies, a wide variety of stressors, like physical pain or minor daily hassles have been demonstrated to increase harmful social reactions such as aggression in both animal models and human participants (for reviews, see Sprague et al., 2011; Takahashi et al., 2018) . However, the role of stress caused by social quarantine and constant low-level threat due to uncertainty during the pandemic and how this might relate to increased hostility is rarely studied. In the present study, hostility is defined as comprising feelings and/or behaviors characterized by anger expression such as aggression, irritability, rage, and resentment (Holi, 2003) . In addition, it was proposed that stress per se is less crucial to mental health than coping strategies a person uses in response to stress (Compas et al., 2001) . The construct of coping, the cognitive and behavioral strategies to meet the demands of stressful situations, has been considered an important mediator of the stress-emotion relationship (Folkman & Lazarus, 1988; Main et al., 2011) . Coping can be described as negative/avoidant (e.g., distraction, withdrawal, wishful thinking, substance use) or positive/approach (e.g., problem-solving efforts, seeking information) (Day & Livingstone, 2001). Moreover, researchers have found that positive/approach coping is generally related with less psychological symptoms, while negative/avoidant coping is associated with more symptoms in the Chinese population (Ding et al., 2015; Zheng et al., 2012) . Furthermore, it is important to examine the social factors that might protect an affected population from developing hostility. Social support of individuals by family, friends and even institutions have been widely demonstrated to have positive effects on both physical and psychological well-being, and also to have a moderating effect of stress on health, the so-called "stress-buffering hypothesis" (Cohen & Wills, 1985) . According to this hypothesis, the moderation effect of social support on stress may arise through both processes depending on the amount of social support (main effect) and processes depending on the interaction of the stress level and the amount of social support (buffering effect).

The buffering effect of social support, therefore, becomes more crucial as the stress level individuals perceived increases. Consistent with stress-buffering hypothesis, we predicted that social support might act as a buffer between stress and hostility. Therefore, the first aim of the current study was to explore the effect of the COVID-19 pandemic on mental health of a general Chinese population sample during the course of acute pandemic activity the peak of the outbreak (January 31 st to February 9 th ) to the epidemic's remission phase (15 th to 28 th of March) at the individual level. The second aim was to examine whether perceived stress level to the COVID-19 pandemic would predict an increase in hostility and whether coping strategies would play a potential intermediating role in the relationship between stress and hostility. It was expected that the underlying mechanism between stress and hostility would function through coping strategies, such that higher perceived COVID-19 stress would be related with an increased use of negative coping, which, in turn, would lead to more general hostility. The third aim was to identify protective psychosocial factor from the perspective of perceived social support in the relationship between perceived stress and hostility in the general population sample.

According to the stress-buffering effect, individuals with high stress level benefit more from social support than individuals with low stress level (Cohen & Wills, 1985) . Therefore, it was expected that social support would act as a protective factor between stress and hostility.

This study was conducted from January 31 st to February 9 th (first wave of the survey, T1) and March 15 th to March 28 th (second wave of the survey, T2), which covered the time from the peak of the outbreak to the remission of COVID-19 epidemic in central China. As is shown in Fig. 1 , at the first timepoint of this study, China was undergoing a difficult period during which the confirmed and suspected cases reached its peak, and pressure on the healthcare system was intensified. There was little information about the causal agents and available treatment methods for the disease. were asked to fill in the questionnaire according to their current situation in a relatively quiet environment to avoid interference as much as possible. They were also informed that their personal information and responses will be kept anonymous and confidential. This study was approved by the Ethics Committee of Peking University. All participants provided electronic informed consent before the commencement of the two waves of survey. The lines indicate case counts per day of confirmed cases in yellow (note the spike of confirmed case on 14 th of February was due to a change in diagnostic criteria from only by test kits to clinical (radiological) diagnosis of patients), suspected cases in blue, recovered cases in green and casualties in red.

To assess the perceived stress to the COVID-19 epidemic, Perceived Stress Scale during the second wave of the survey. All the questionnaires were described in detail in the following part.

The PSS10 includes 10 items assessing stress for the past one month during the COVID-19 epidemic. This scale was originally compiled by Cohen (1983) and the revised Chinese version has been demonstrated to have good reliability and validity (Yang et al., 2003 ). An example item is "during the outbreak, how often have you felt that you were unable to control the important things in your life". Each item is rated from 1 (not at all) to 5 (very much). The average score is calculated by the sum of each item score divided by the total number of items (range: 1~5). The higher the score, the more stressed the respondent is. The PSS10 demonstrated good internal consistency (α = .801) in the current sample.

The mental health status during the COVID-19 pandemic was measured by the 

The Hostility subscale of the SCL-90 (Derogatis & Savitz, 1999 ) was used to measure hostility levels in the second wave. This hostility subscale comprises 6 items such as temper outbursts that you could not control in the past one week, and each item is assessed by a 5-point Likert scale (0 = "not at all" to 4 = "all the time"). The average score is calculated by the sum of each item score divided by the total number of items (range: 1~5). An example item is "how often did you get into frequent arguments within the last week". It reflects the respondents' hostility from three aspects:

thoughts, emotion and behavior. In the current sample, the internal consistency coefficient is α = .858.

Coping style has been widely investigated around the world. However, the difference in research aims contributed to various evaluation tools for coping style. In China, one of the main understandings of coping style is defined it as the tendency an individual is used to adopting. Based on this, Xie (1998) Considering the characteristic of "collectivism" in Chinese culture, the Chinese PSSS includes not only supports from family and friends, but also supports from others government. For example, "when we need help, our nation's medical forces can be the first to provide help". This scale was used to measure the subjective and perceived social support of participants in the second wave. The degree of support is rated and average score is calculated (range: 1~7), with higher score indicating more perceived social support. The internal consistency of our research is α = .828.

All the statistical analysis was conducted by IBM SPSS Statistics, version 24.0 (IBM For the second and third aim, the intermediating role of coping styles and the moderating role of perceived social support on hostility were analyzed by PROCESS macro (Model 1 and Model 4). In these models, we controlled for sex, age, education, monthly income, and quarantine experience (T1 and T2). All continuous variables were standardized and the interaction terms were computed from these standardized scores. The bootstrapping method produces 95% bias-corrected confidence intervals of these effects from 5,000 resamples of the data. Confidence intervals that do not include zero indicate effects that are significant (Hayes, 2013) . The standard error of the linear regression model is estimated using HC3 as proposed by Davidson and MacKinnon (1993).

Demographic description of the respondents who participated in the two waves of the survey (n = 1390) are shown in the 

To explore predictors of depression level at T2, a hierarchical regression model was used. Specifically, for independent variables, depression level and quarantine experience measured in Wave 1 were placed in the first step as the controlled variables; demographic variables (i.e., gender, age, education and monthly income), which were all measured in Wave 1, were entered in the second regression step; and increase in perceived stress as well as quarantine experience measured in Wave 2

were placed in the third step. As Table 3 shows, after controlling initial depression level (depression_T1) and initial quarantine experience (quarantine_T1), ΔPSS10 (β from T1 to T2 is associated with higher depression level at T2. Quarantine experience at T2 (β = -.063, p < .05) significantly predicted depression at T2, such that respondents who have the recent experience of quarantine reported higher depression level at T2. Furthermore, age (β = -0.056, p < .05) and monthly income (β = -0.054, p < .05) were also significant predictors, indicating that younger people and individuals with lower income experience worsening depression symptoms. 

There was a significantly positive correlation between PSS10 at T1 and hostility at T2 (r = .382, p < .001). In the hierarchical model, initial perceived stress and quarantine experience measured in Wave 1 were placed in the first regression step; demographic variables (i.e., gender, age, education and monthly income), which were all measured in Wave 1, were entered in the second regression step; and quarantine experience measured in Wave 2 was placed in the third step. The result (see Table 4 ) showed that the level of perceived stress at T1 (β = .366, p < .001) significantly predicts the higher level of hostility at T2. Additionally, age (β = -.082, p < .001) negatively predicts the hostility such that younger people show higher hostility in general. The level of hostility at T2 was positively correlated with negative coping (r = .287, p < .001) and negatively correlated with positive coping (r = -.123, p < .001), which provided a precondition for testing the intermediating effect of coping styles of stress-hostility relationship.

A mediation model was built in which perceived stress at T1 was treated as a predictor, the level of hostility at T2 as the outcome variable, negative and positive coping as mediators, and demographic variables (gender, age, education, and monthly income) as covariates.

This mediation model was tested using the PROCESS macro (Model 4) developed by Hayes (2013) . As reported in Table 5 , perceived stress at T2 is negatively correlated with positive coping (β = -.167, p < .001) and positively correlated with negative coping (β = .055, p < .05). Furthermore, positive coping at T2 negatively predicted the level of hostility at T2 (β = -.161, p < .001), while negative coping at T2 positively predicted the level of hostility at T2. Furthermore, positive coping and negative coping at T2 independently intermediates the relationship between perceived stress at T1 and the level of hostility at T2 (see Result in supplementary material). The results of mediation effect are summarized in Fig. 3 . To summarize, positive coping negatively intermediates the effect of stress on hostility, while negative coping positively intermediates the effect of stress on hostility. 

There was a significantly positive correlation between PSS10 at T1 and hostility at T2 (r = .382, p < .001). Meanwhile, perceived social support at T2 was negatively correlated with the level of hostility at T2 (r = -.208, p < .001). Therefore, the PROCESS macro (Model 1) by Hayes (2013) was used to test whether perceived social support at T2 could moderate the relationship of perceived stress at T1 and the level of hostility at T2. As displayed in Table 6 , the interaction effect of perceived stress at T1 and perceived social support at T2 could negatively predict the level of hostility at T2 (β = -.081, p < .001). To further explain the interaction effect, the relationship between perceived stress at T1 and hostility at T2 was plotted. As the moderator, the levels of perceived social support at T2 was divided into low (M -SD) and high (M + SD), respectively. The results showed that as the level of perceived social support at T2 reduced from high to low, the predictive effect of perceived stress at T1 on the level of hostility at T2 was gradually strengthened, and β increased from .241 (p < .001) to .402 (p < .001) (See Fig. 4) . Therefore, perceived social support buffered the relationship between elevated perceived stress and elevated hostility. 

In the current study, we investigated the temporal change of mental health status in a sample of the Chinese population from the peak to the remission phase of the COVID-19 pandemic. We found that compared to the peak phase, levels of perceived stress and fear decreased, while depression levels were significantly increased during the remission phase. Regression analysis showed that younger age, lower income, higher perceived stress to the COVID-19 pandemic as well as current quarantine experience (measured at T2) are risk factors of depression deterioration. Furthermore, we found that the younger age and initial perceived stress during the peak phase predict more hostility in its remission phase. Our mediation model showed that However, due to the cross-sectional design, these two studies could not clarify whether these symptoms were elevated above the level as when the pandemic occurred. An assessment of hospital employees in China found that compared to a non-segregated sample, the experience of being segregated during SARS was associated with high depressive symptoms three years after the epidemic . With a prospective design, our study provided insights for depression development under the epidemic in the general population. Individuals who are young, economically disadvantaged, who have been socially isolated or quarantined and who show a strong initial stress response might be particularly at risk for elevated depression in the aftermath of such a pandemic.

We found that younger people expressed more hostility in this COVID-19 epidemiological situation, which might be due that younger adults adopt ineffective emotion regulation supported by cognitive control (Jackson & Finney, 2002) . After reviewing data from structural and functional brain imaging, Nashiro and colleagues (2012) found that with preserved amygdala in older adults, they show greater prefrontal cortex activity than younger adults while engaging in emotion-processing tasks. Furthermore, individuals perceived higher stress of the COVID-19 pandemic at the peak of the outbreak predicted more hostility at the remission phase of the epidemic. This is consistent with Berkowitz's (1990) However, our mediation model showed that relations between perceived stress and hostility could be accounted for by the coping strategies individuals selected. This is consistent with stress and trauma literature that the association between life stress and psychological adjustment is strongly mediated by coping strategies (Runtz & Schallow, 1997; Tremblay et al., 1999) . Positive coping, such as problem-solving efforts, seeking information and cognitive reappraisal, involves focusing on the cause of the stress and attempting to actively do something to mitigate the stress (Carver et al., 1989) . Individuals with positive coping strategies believe they have more control over the situation and might in turn develop fewer hostile responses to a stressful situation. Negative coping, such as denial, withdrawal, wishful thinking and substance use, involves emotion-focused passive coping strategies in an attempt to reduce the emotional stress elicited by a stressful situation. Individuals with passive coping believe they have little control over the situation (Folkman & Lazarus, 1980; , and therefore display more hostility to the environment.

Furthermore, the relationship between perceived stress and hostility was moderated by social support, which was consistent with the stress-buffering effect that social support has. Compared to individuals with lower levels of stress, individuals with higher levels of stress show a more substantial and beneficial influence of social support (Cohen & Wills, 1985) . Our study provides some implications for public mental health. First, it is crucial to develop and implement effective screening procedures at the institutional level to identify risk and resilience factors to provide precise intervention (Yang et al., 2010) .

In this context, we identified that younger people are at risk of both depression and hostility in the aftermath of the COVID-19 pandemic. Second, the effect of pandemic-related stress on emotional disturbance (especially depression) suggests the importance of early individualized psychological intervention in the general population, with a focus on individuals who are economically disadvantaged, individuals who have been quarantined and individuals that exhibit high levels of stress. Third, positive coping strategies as well as social support should be encouraged even in the context of social distancing.

There are some limitations to our study. First, we investigated a Chinese sample only to assess the temporal dynamics of mental health during this pandemic, which limits generalizability to other countries. In the same vein, the questionnaires we used here are not for clinical diagnosis and include constructs that capture culturally-dependent phenomenon such as neurasthenia, social support from the government level. Second, all the constructs in the current study were assessed by self-report. However, more and more studies reach the consensus that it is the subjective appraisal rather than the stressor itself that has large impacts on mental and physical health (Mathur et al., 2016; Pascoe & Smart Richman, 2009 ). Third, the retention rate from the first wave to the second wave in our study was low (approximately 43%). The respondents who participated in the two waves were mainly young and well-educated who might also be more physically and psychologically resilient. Older and socio-economically disadvantaged people might constitute a population that is more at risk for severe trajectories of the disease and also consequently might be more prone to perceived stress.

Despite these limitations, our study tracked the psychological change at the individual level during the peak and remission phase of the COVID-19 epidemic in China. Fear significantly decreased while depression level significantly increased over the course of the pandemic. We identified that younger age, lower income, higher perceived stress, and current quarantine experience are risk factors for depression deterioration. Younger age and higher initial stress predicted higher hostility, which was mediated by negative coping style. Furthermore, social support can buffer the effect of stress on hostility. Our results might provide implications for public mental health intervention.

Declaration of Competing Interest: The authors declare no competing interests. 

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