key: cord-0880441-hlzqptms
authors: Zhao, Sheng Zhi; Wong, Janet Yuen Ha; Luk, Tzu Tsun; Wai, Abraham Ka Chung; Lam, Tai Hing; Wang, Man Ping
title: Mental health crisis under COVID-19 pandemic in Hong Kong, China
date: 2020-09-16
journal: Int J Infect Dis
DOI: 10.1016/j.ijid.2020.09.030
sha: a15f4e5a509dbfe6c588dc2e50917043501e4bd9
doc_id: 880441
cord_uid: hlzqptms

Objectives To compare the mental health burden before and during the COVID-19 outbreak and identified vulnerable groups by sociodemographic factors. Methods We analyzed repeated cross-sectional data from Hong Kong Family and Health Information Trend Survey (FHInTS) in 2016 (N = 4036) and 2017 (N = 4051) and COVID-19 Health Information Survey (CoVHInS) in April 9 to 23, 2020 (N = 1501) using population-based random samples of general adults by landline telephone and online panel. Stress (Perceived Stress Scale 4), anxiety symptoms (General Anxiety Disorders 2), depression symptoms (Patient Health Questionnaire-2), subjective happiness (4-point Likert item), and sociodemographic were collected. Results Compared with 2016 and 2017, the stress level increased by 28.3%, prevalence of anxiety increased by 42.3% and the depression symptoms and unhappiness have doubled (all p for trends <0.001) during the COVID-19 outbreak. The increases in stress level were significantly larger among older and less educated respondents (P for interactions <0.001). Conclusion Hong Kong had a mental health emergency even with no lockdown and well-managed outbreaks. Older and under-privileged people will suffer most. Public mental health interventions are urgently needed particularly for the older adults and individuals with primary or lower education attainment.

Globally, mental health crises are emerging under the COVID-19 pandemic. Monitoring the population mental health burden and identifying vulnerable groups for targeted assistance is a public health priority (Wang et al., 2020a) .

In Hong Kong, the first COVID-19 was reported on Jan 18, 2020. The outbreak peaked in late March with 1035 confirmed cases by 23 April 2020 . Hong Kong has been praised as a model of successful control of the outbreak without enforced lockdown, but with high compliance of social distancing and voluntary mass masking in the population since end of January . By combining data from two past population-based surveys conducted in 2016 and 2017, and a new survey in April 2020, we compared the population mental health symptoms before and during the outbreak and identified vulnerable groups by sociodemographic factors.

We analyzed repeated cross-sectional data from Hong Kong Family and Health Information Trend Survey (FHInTS) (Zhao et al., 2019) in 2016 (N=4036) and 2017 (N=4051) and COVID-19 Health Information Survey (CoVHInS) in April 2020 (N=1501) with response rates of 74.4%, 70.2% and 61.3%, respectively. We used random digital dialing by landline telephone to sample Chinese-speaking adults aged 18+ years. CoVHInS additionally sampled respondents from a population-representative mobile online panel for rapid recruitment (response rate 61.7%).

Respondents sampled from landline numbers were interviewed via telephone, whereas those from the mobile panel self-administered the survey online.

Stress was measured by Perceived Stress Scale-4 (PSS-4), score ranged from 0 to 16 with higher score indicating higher stress level (Cohen et al., 1983) . Anxiety and depression symptoms were J o u r n a l P r e -p r o o f measured by the General Anxiety Disorders-2 (GAD-2) and the Patient Health Questionnaire-2 (PHQ-2), both ranged from 0 to 6 and a score of ≥ 3 indicates anxiety or depression symptom, respectively (Kroenke et al., 2009) . Subjective happiness was assessed on a 4-point Likert item rated from "very happy" to "not happy at all" (Oswald & Wu, 2010) . Sociodemographic factors were collected. Data were weighted by sex, age and education distributions in the general adult population. We used multivariable regressions to examine population changes in mental health symptoms by survey year, adjusting for sociodemographic. Analyses were performed using STATA 15.1 (StataCorp., USA). The Institutional Review Board of the University of Hong Kong/ Hospital Authority Hong Kong West Cluster approved the studies, informed consent was obtained.

The stress level and prevalence of anxiety and depressive symptoms and subjective unhappiness were similar between 2016 and 2017 but greatly increased during the COVID-19 outbreak (Table   1) . Compared with 2016, the proportion of unhappiness and depressive symptoms doubled, mean score of PSS-4 increased by 23.1% and proportion of anxiety symptom increased by 39.8% (all P for trends <0.001). Subgroup analyses by sex, age and education showed that respondents who were older (aged 60+) tend to have larger increase in all mental health outcomes. The increases in stress level were significantly larger among older and less educated respondents (P for interactions <0.001) ( Table 2) .

This is the first report showing alarming increases in mental health symptoms after a long period of social distancing and severe disruption of daily life (about 10-12 weeks) under COVID-19 in an overcrowded city where people were free to go out anytime and restaurants and shops remained open. Our results show that Hong Kong had a mental health emergency even with no J o u r n a l P r e -p r o o f lockdown, and suggest the magnitude of mental health crisis would be greater in countries with more severe outbreak and more stringent containment policies. During the initial phase of the outbreak in China, moderate-to-severe anxiety and depression symptoms were reported by 28.8% and 16.5% respondents, respectively (Wang et al., 2020b) . Mental health burden in other epicenters warrants further investigation. We have shown that older and under-privileged people will suffer most. Targeted public health interventions are urgently needed particularly for the older adults and individuals with primary or lower education attainment. Health information and communication should be accessible and suitable for community practice, especially for those who are not comfortable in seeking and processing online information. As face-to-face social interactions and center-based activities are not practicable, the use of social media and urgent mobilization of voluntary community social support and emergency remedy are needed to reduce the harms from mental ill-health especially in the most vulnerable.

This study has several limitations. Data on mental health burden in 2018 and 2019 (with major social unrest since June 2019) are unavailable, however the prevalence of depression remains higher in April 2020 (14.8%) than that in fall of 2019 (11.2%) reported in another survey (Ni et al., 2020) . Cross-sectional design restricted the causational interpretation. The simple measures we used for mental health symptoms have limited the clinical implications and more rigorous measurements were warranted (Hao et al., 2020) . Personality traits and pre-existing psychological problems were not controlled. 

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