key: cord-0893573-jcqce7jo authors: Ujhelyi Gomez, K.; Corcoran, R.; Ring, A.; Hassan, S.; Abba, K.; Downing, J.; Goodall, M.; Gabbay, M.; Clarke, P.; Moran, P.; Obe, D. A.; Bennett, K. M. title: Characteristics of mental health stability during COVID-19: An online survey with people residing in the Liverpool City Region date: 2022-03-18 journal: nan DOI: 10.1101/2022.03.17.22272479 sha: b3624a577167f67166ffd6b60ffcdb17b43530d1 doc_id: 893573 cord_uid: jcqce7jo Background and aim : Despite the significant mental health challenges the COVID-19 pandemic and its associated government measures have presented, research have shown that the majority of people have adapted and coped well. The aim of this study was i) to determine the proportion of people with mental stability and volatility during the pandemic in a North West urban environment sample and ii) to establish group differences in psychosocial variables. Mental stability and volatility refer to the extent to which individuals reported change in levels of common mental health symptoms over the course of 12 weeks. Method : a two-wave-online survey (N = 163) was used to explore the psychological and social impact of the pandemic on relatively disadvantaged neighbourhoods within the Liverpool City Region over 12 weeks. Kruskal-Wallis with post-hoc tests were used to determine how people with mental stability and volatility differed on factors categorised within an ecological framework of resilience (individual, community, societal, and COVID-19 specific). Results : Individuals categorised as stable in terms of mental health symptoms (63.6%) had better mental and physical health; were more tolerant of uncertainty; reported higher levels of resilience and wellbeing compared to very volatile people (19.8%). These individuals also reported feeling less socially isolated, experienced a greater sense of belonging to their community which was more likely to fulfil their needs, and were more likely to have access to green space nearby for their recommended daily exercise. Stable individuals did not report worrying any more during the pandemic than usual and tolerated uncertainty better compared to those in the volatile group. Implications : The majority of participants in this sample were mentally stable and coping well with the challenges presented by the pandemic. The resilience of these individuals was related to key place-based factors such as a strong sense of community and useable local assets. The data showcase the role of place-based social determinants in supporting resilience and thereby highlight key preventative measures for public mental health during times of international crisis. C O V The novel coronavirus SARS-CoV-2, rapidly spread across the world becoming a global pandemic by March 2020. As a response to tackle the virus and limit its spread, the UK Government initiated a national lockdown on the 23 rd of March 2020 that lasted for over four months. This was followed by various levels of restrictions and public health advice throughout the country for the coming months from social distancing and working from home, mask wearing and hand hygiene through to stringent domestic and international travel restrictions. The ongoing pandemic and the associated government measures have dramatically changed the way people live, work, and socialise 1 . Several research groups have reported that the coronavirus pandemic has presented significant mental health challenges [2] [3] [4] [5] . In line with findings in other countries (e.g. 6, 7 ) , the Office of National Statistics (ONS) have reported elevated distress indices, such as increased levels of anxiety (32%), diminished well-being (43%), and loneliness (23%) among the UK population 8 . However, some studies have identified different trajectories for mental health (e.g. 9,10 ). For example, Shevlin et al. (2021) found five classes reflecting stability (low stable and high stable), improvement and two classes of deterioration (one more severe than the other). The most common trajectory was a low-stable profile, which could be termed resilient. A systematic review and meta-analysis of 65 pandemic mental health cohort studies suggest that the initial increase in mental health symptoms resolved towards the norm with time, which has been suggested to demonstrate the impact of resilience 11 . N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -1 9 4 Resilience has been defined as a psychological trait which promotes well-being 12 or a process 13 leading to an outcome 14 . Windle (2011) 13 , following from a comprehensive concept analysis, defines resilience as "the process of effectively negotiating, adapting to, or managing significant sources of stress or trauma. Assets and resources within the individual, their life and environment facilitate this capacity for adaptation and 'bouncing back' in the face of adversity." 13 . Resilience can also be considered as a capacity for mental stability or toughness 15 through adapting and bouncing back in the face of challenge 14 , protecting against stress, trauma, and adversity 16 . However, there are wider determinants of resilient responses to negative situations and trauma 17 . To account for the interaction between different levels of factors that can influence a person's resilience, an ecological model of resilience has been proposed 18 . This framework (Fig 1) recognises that resilience operates interactively in context at individual, community, and societal levels 13, 19 . Individual resilience thus develops amidst an interplay of environmental-community and social-political factors, most of which are beyond individual control 20 . Higher resilience has been linked to reduced psychological symptomatology 21 and distress 22 , as well as increased wellbeing [23] [24] [25] . Preliminary data indicates that the pandemic has increased people's acute and chronic stress levels due to the uncertainty and uncontrollability of the pandemic's impact on broad aspects of autonomy, health, family and finances 26 . COVID-related resilience has been negatively associated with symptoms of depression, anxiety, somatisation, and negative emotional symptoms 27 . People have been M E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -1 9 5 shown to cope with the pandemic through connections with loved ones, going outdoors, physical activity, via spirituality 28, 29 , leading a healthy lifestyle, accepting anxiety and negative emotions, and inquiring information about medical treatment 30 . In a test of the ecological model of resilience during the pandemic in Italy, evidence supporting the role of individual, societal and COVID-specific levels of the model (but not community), was found. Key contributors to resilience in this study included: psychological variables such as conscientiousness and intolerance of uncertainty; demographic variables such as having children in the home and educational level; and covid-specific variables such as COVIDspecific anxiety, and social distancing 31 . In the UK, the COVID-19 crisis has had a particularly negative effect with one of the highest mortality rates in the world 32 . Uncertainty is always challenging and can contribute to the development of generalised anxiety, depression, and health anxiety 33 . A study of 555 UK adults 34 observed high levels of generalised anxiety (27%) as a result of the pandemic that was more than four times the national average pre-pandemic 5.9%; 35 . The figure was also higher compared to rates identified by previous pandemic research (e.g. 36, 37 ). However, increased anxiety, loneliness, distress and low mood are normative experiences during such a crisis and it is one's response to these negative emotions that ultimately influence longer-term mental health outcomes 38 . Individual responses to stress are affected by coping style, available social support, previous experience with the specific stressor, underlying mental health issues, and personality characteristics 26 . While the negative mental health impact of the pandemic is real, generally, adaptation and recovery are the typical responses to trauma and adversity 39 . This is apparent in research findings among the UK population collected during the pandemic. In spite of struggles as the crisis unfolded in the UK, 64% of people who responded to a national longitudinal survey reported coping well 10 , using adaptive coping strategies, such as going for a walk, spending time in open . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -1 9 6 spaces, staying connected with others, or exercising 40, 10, 41 . Another study found the prevalence of psychological problems at the early stage of the crisis only slightly higher than during previous pandemics suggesting again the population's successful adaptation to the situation 42 . As mentioned previously, in a longitudinal study of more than 2000 participants, Shevlin et al. (2021) 9 identified five profiles (low stable; high stable; improving; and two deteriorating profiles). They found that psychological variables distinguished between the low-stable and the other profiles. Research that helps us understand the wide range of determinants that impact on individual ability to respond resiliently can facilitate evidence-based policy management of future or ongoing crises. Moreover, while research has been conducted on a national level, indepth localised research in areas where the pandemic hit harder is relatively lacking. In order to fill the above research gaps, the current study adopted a resilient systems approach to understand individual responses to the pandemic. Additionally, it investigated the psychological and social impact of the COVID-19 pandemic and its associated lockdown restrictions in a city region located in the North of England with high levels of deprivation and thus higher level of vulnerability to the pandemic. M E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -1 9 7 to volatility or change in mental health. The study aims to establish i) the proportion of people with mental stability and mental volatility and ii) differences between groups in terms of demographic, psychological, societal, community, and COVID-specific factors. These data are part of a larger study surveying households early in the COVID-19 pandemic and then twice more in three months. The study explored the psychological and social impact of the pandemic and its associated restrictions on relatively disadvantaged neighbourhoods within a city region in the North West, and factors influencing response to and impact of the pandemic. An online survey using JISC software was launched in mid-June 2020 and conducted three times, across a 12-week period (week 1, week 6, week 12). Participants were recruited using several methods including re-contacting, by telephone or mail, willing participants who had supplied data for either or both wave 1 or wave 2 of the NIHR CLARHC North West Coast Household Health Survey (CLAHRC NWC HHS) 43 and by advertising the research via local media (newspaper, radio) and social media (Twitter, Facebook). The first phase of the survey collected data from 290 LCR residents. Baseline responses were collected between mid-June and the end of August 2020. While the survey included 3 waves, the data collected at week 6 was a much-abbreviated set of questions focussing on behaviours and pastimes only. The analyses reported here uses the . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) 8 fuller data collected in the first and third waves, representing 12 weeks of individual pandemic experience between mid-June and mid-December 2020. Automated reminders to complete the current wave of the survey were generated through the JISC software. Ethical approval was granted by the University of Liverpool Central Research Ethics Committee (7739). Informed consent was collected at the beginning of the first survey. Noncompletion of this survey and follow-up surveys was treated as withdrawal of consent such that only data from individuals who reached the end of the survey was included in this dataset. As a result, missing data was minimal. This extensive survey assessed a wide range of psychological and social determinants. For the full list of measures used refer to Supplemental Table ( The 9-item Patient Health Questionnaire (PHQ-9) 44 Anxiety Disorder (GAD 7) questionnaire 45 were used to measure self-reported common mental health symptoms. On both measures, responses range on a four-point Likert scale from 0 'not at all' to 3 'nearly every day'. The higher the total score, the more severe the . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) symptoms. Both scales measure symptoms over the past week in this survey. The PHQ-9 is a valid and reliable measure (Cronbach's α =0.86) not only for the identification of depression but also to measure its severity which makes it ideal to track changes in depression levels over time 44 . Similarly, GAD-7 is a valid and efficient tool (Cronbach's α =0.91) to screen anxiety and its severity in clinical practice and research 45 . As symptoms of depression and anxiety are typically co-morbid and with a view to meaningfully simplifying subsequent analysis, the GAD-7 and the PHQ-9 scores were summed to create a single common mental health (CMH) variable for the week 1 and week 12 data. The degree of stability or volatility of this CMH variable between week 1 and week 12 provides the working measure of individual resilience through 12 weeks of the pandemic. More detail on this derived variable is presented in the data analysis section below. Demographic characteristics measured included age, gender, marital status, and accommodation. Sociodemographic variables collected were level of education, subjective assessment of financial status before the pandemic; current subjective financial status; work status before the pandemic and current work status. The 7-item (SWEMWBS) 46 1 0 indicate the extent to which they agreed with each statement on a scale of 1 to 5 where 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree. Items 1, 3, and 5 of the scale are positively worded, and items 2, 4, and 6 are negatively worded. The BRS was used to test construct validity of the common mental health change outcome variable, anticipating that the 'stable', 'volatile' and 'very volatile' groups would differ significantly with respect to their scores on the BRS. The 12-item two-factor (prospective and inhibitory anxiety) version 48 The Brief Sense of Community Scale 50 is an 8-item sense of community scale representing factors of needs fulfilment, group membership, influence and emotional connection to neighbourhood. The scale incorporates a five-point self-report Likert scale with end points from strongly agree to strongly disagree. Additionally, respondents were asked whether they had access to a pleasant local green/open space for their recommended daily exercise; if they felt isolated from others and, . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 18, 2022 whether they would feel comfortable/uncomfortable asking a neighbour to collect a few shopping essentials for them if necessary. Participants also provided answers regarding whether they surfed the Internet more or less often than usual, or about the same as before the pandemic. Participants were asked whether they had been or were volunteering to support their local coronavirus action; whether they had experienced worry, and whether they had felt anxious about their work situation (or the work situation of others close to them) and / or about the future. For the data analyses, variables were recoded to overcome some limitations posed by low cell sizes. See ST 2 for details. The depression and anxiety scores on the PHQ-9 and GAD-7 for week 1 (N=163) and week 12 (N=162 due to one missing score on the GAD-7) were combined to create a composite 'common mental health' (CMH) variable (N=162). A 'CMH change' variable was then created (N=162) to reflect change in reported common mental health symptoms over the 12 weeks. This was used to create a three-level variable to capture stability versus volatility (stable, volatile, and very volatile cases) using the standard deviation of the 'CMH change' variable (SD=8.17) where 'stable' people represented those whose scores fell between -4 and +4 (no change in mental health), the 'volatile' group included people whose scores fell between -4 and -8, and +4 and +8 (some change in mental health), and the scores of 'very volatile' individuals were anywhere below -8 and above +8 (greater change in mental health). . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 18, 2022 M E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -M E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -M E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D - No significant group differences were identified in terms of demographic factors. The analysis revealed statistically significant differences across 'stable', 'volatile' and 'very volatile' people in terms of intolerance of uncertainty, subjective health, and wellbeing. Further analyses among the groups revealed that 'stable' people reported being significantly more tolerant of uncertainty compared to 'volatile' and 'very volatile' people. This group also reported statistically significantly higher levels of subjective health, and wellbeing compared to 'very volatile' people. There was a significant association in relation to social isolation among the groups with the 'stable' group being significantly less likely to be socially isolated than 'very volatile' individuals. Significant differences were also found regarding sense of community, more specifically, in level of needs fulfilment and community membership. Those with stable mental health over time reported a significantly higher level of needs fulfilment from, and membership of, their community as measured by the BSCS compared to their 'very volatile' counterparts. These findings remained significant after Bonferroni adjustment (p<.017). . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 18, 2022 M E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -1 9 1 9 Access to a pleasant local open or green space for recommended daily exercise was associated with stability. The 'stable' group was more likely to have access to appropriate green space than both 'volatile' and 'very volatile' people, but the association after Bonferroni adjustment (p<.017) only remained between 'stable' and 'very volatile' people. There was a statistically significant difference in coronavirus-related worry across the three groups. A significantly higher proportion of the 'stable' group reported unchanged levels of worrying compared to 'volatile' and 'very volatile' groups with the association between stable and 'volatile' people remaining significant after adjustment (p<.017). include further information on these results. Fig. 3 here is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 18, 2022 N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -1 9 2 4 Adopting a resilient systems approach, the present study aimed to i) determine the proportion of people with mental stability and mental volatility during the COVID-19 pandemic in a sample of people in a city region in the North West of England and ii) establish differences between groups (stable, volatile, very volatile) in terms of individual (demographic, psychological), community, societal, and COVID-19 specific factors. Participants with low level or no change in their mental health symptoms over the course of 12 weeks were included in the 'stable' group reflecting their ability to adapt and cope well with the challenges of the pandemic. Associations were found between mental stability/volatility and common mental health and resilience providing validity for the use of this concept. The findings revealed that nearly two thirds of the participants (63.6%, 'stable' group) were coping well during the first phase of the health crisis and individual, community, societal, and COVID-19 specific mechanisms were associated with mental stability and volatility. About one third of the participants were experiencing anxiety during the first lockdown. This is similar to reports of 32% by the ONS (2020), slightly higher than other previous UK findings of 27% 34 , and considerably higher than pre-pandemic figures in the general UK population (5.9%) 35 . However, this heightened level of anxiety is a normal response to an unprecedented public health crisis and lockdown measures. Whether it persists and becomes a long-term mental health problem depends upon a person's response to the stress and their ability to cope 38 . As the results of this study show, approximately 64% of those who completed the survey at both time points can be characterised as mentally stable, thus coping well with the pandemic and its restrictions, which is in line with previous research findings 31, 10 . This means that anxiety and depression levels remained stable over the 12 weeks for these individuals demonstrating that their mental health did not suffer during this time. The ecological model of resilience usefully accounted for the multiple sources, within the individual, as well as their life and environment, that can impact on resilience, explaining the differences between mentally 'stable', 'volatile', and 'very volatile' people. Although the groups did not differ in terms of demographic and socio-demographic factors, they were different at the psychological, community, and societal levels. At the individual level, mental stability was associated with higher level of wellbeing and mental and physical health. This link between resilience, coping, mental and physical . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 18, 2022 M E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -1 9 2 6 health, and wellbeing has been clearly indicated by an extensive prior literature (e.g. [23] [24] [25] 27 ). Moreover, mental stability during the pandemic was characterised by a better tolerance of uncertainty, which has also been demonstrated in an Italian sample 31 . People have been shown to cope with the health crisis through connections with 28 and support from loved ones 29 . Social connections can also affect how people respond to stress 26 . In our study, mentally stable individuals reported feeling less socially isolated. It is known that communities are important in supporting individual resilience 51 and encouraging healthy coping behaviours 52 . Sense of community, such as feeling a sense of belonging and a perception that one's needs will be met by the community, has been associated with better mental health 50 . Mentally stable people of this study reported their needs being met as members of their community and feeling a sense of belonging to this community. At the societal level, those who were coping better reported having an open green space nearby which they could use to take the recommended daily exercise during lockdown. There is increasing evidence of the association between wellbeing and outdoor activity and this has also been shown to be the case during the pandemic 28, 29 . COVID-19-related anxiety has been found to hinder resilience 31 . In the present sample, those identified as mentally volatile were characterised by excessive worry in the midst of the pandemic compared to those mentally stable who described their level of worry as 'about the same' as prior to the pandemic. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) M E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -1 9 2 7 These findings demonstrate that mental stability or resilience operates in an interactive way at multiple levels 13, 20 . While individual factors are important in adaptation to adversity and coping with stress, the activation of local assets to enable communities to cope with natural disasters and isolation are also necessary 51 . Therefore, the wider determinants of health, such as the community and society we live and work in, are key to enabling the public to bounce back after adversity 20 . Research has demonstrated that some groups in society have been disproportionately affected by the pandemic, such as ethnic minority communities 53 and older people 54 underpinned by health inequalities and unfairness. Some of the greatest drivers of health inequalities include environmental and community factors, such as extent of social isolation, unequal availability of good quality green space nearby, and differing levels of sense of community. These are also the drivers of mental health difficulties and, importantly, they are factors over which the individual can have very little control. Therefore, public health interventions should focus on developing enabling, agentic and supporting environments to facilitate people's ability to gain control over the determinants of their health and thus promote health and well-being 51 . The factors that were found to affect mental stability may also have an impact on people's willingness to uptake COVID-19 vaccination. Future research, therefore, could utilise these findings to draw comparison, develop theory, and plan interventions. In addition to inviting participants from the CLAHRC NWC HHS 43 , recruitment was extended to utilise local and social media which boosted participation in the study. This recruitment strategy ensured the recruitment of a sample from varied neighbourhoods (Table 1) including the most deprived areas of the city region, 55 . The high levels of IMD in this sample may reflect the high levels of IMD in this region compared to the national profile, . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) M E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -1 9 2 8 which may explain the lack of significant findings with regard to sociodemographic characteristics 55 . Despite the extended recruitment, the week 1 survey sample was relatively small (N=290) and it was further reduced by high attrition in the 12-week follow-up (N=163). Additionally, a high proportion of the participants were women, individuals of white ethnic background (representative of the city region demographic), higher educated, and only the digitally enabled would have the capacity to complete the survey. These are common features of online surveys, which reduce the representativeness of the sample 56 In line with previous research findings, the majority of the participants (64%) with follow-up data at week 12, were mentally stable and coping well with the challenges presented by the pandemic. This is important to record within the context of a relatively disadvantaged urban area. However, it means that the mental health of over a third of the sample during this time of unprecedented adversity was unstable. Understanding the placebased determinants that impact the volatility of mental health is key to facilitate healthy . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted March 18, 2022 M E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -1 9 2 9 coping and the prevention of mental health problems in the population during a crisis. Attending to the wider determinants of health and developing policies that will help to create places that people can use safely and feel a part of will likely benefit the most vulnerable particularly and in doing so will reduce wellbeing inequity and improve population health. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted March 18, 2022 M E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -1 9 3 0 M E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -1 9 3 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted March 18, 2022 M E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -1 9 3 2 M E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -1 9 3 3 M E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -1 9 3 4 M E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -1 9 3 5 M E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -1 9 3 6 M E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -1 9 3 7 M E N T A L H E A L T H S T A B I L I T Y D U R I N G C O V I D -1 9 3 8 Supplemental Table 1 . All measures used in the survey. Measures from which data was used in the current study are bolded. . 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