key: cord-0938272-9eao1kge
authors: Dickerson, J.; Kelly, B.; Lockyer, B.; Bridges, S.; Cartwright, C.; Willan, K.; Shire, K.; Crossley, K.; Bryant, M.; Siddiqi, N.; Sheldon, T. A.; Lawlor, D. A.; Wright, J.; McEachan, R. R.; Pickett, K. E.
title: 'When will this end? Will it end?' The impact of the March-June 2020 UK Covid-19 lockdown response on mental health: a longitudinal survey of mothers in the Born in Bradford study.
date: 2020-11-30
journal: nan
DOI: 10.1101/2020.11.30.20239954
sha: c53bdaa2df69c6534cdf3f969b70992b640bfb8b
doc_id: 938272
cord_uid: 9eao1kge

Objectives To determine clinically important change in anxiety and depression from before to during the first UK Covid-19 lockdown and factors related to this change, including ethnic differences. Design Pre-Covid and lockdown surveys nested within two longitudinal Born in Bradford cohort studies. Participants 1,860 mothers with a child aged 0-4 or 9-13, 48% Pakistani heritage Main outcome measures Odds ratios (OR) for a clinically important increase (5 points) in depression (PHQ-8) and anxiety (GAD-7) in unadjusted regression analyses, parsimonious multivariate modelling to explore ethnicity and mental ill health and lived experience of mothers captured in open text questions. Results Clinically important depression and anxiety increased from 11% to 19%, and 10% to 16% respectively from before to during the first Covid-19 lockdown. Loneliness during lockdown was most strongly associated with increases in depression (OR: 8.37, 95% CIs: 5.70-12.27) and anxiety (8.50, 5.71-12.65), followed by financial insecurity (6.23, 3.96-9.80; 6.03, 3.82-9.51). Other strongly associated variables included food and housing insecurity, a lack of physical activity and a poor partner relationship. When level of financial insecurity was taken into account, Pakistani heritage mothers were less likely than White British mothers to experience an increase in depression (0.67, 0.51-0.89) and anxiety (0.73, 0.55-0.97). Responses to open text highlighted a complex inter-play of health anxieties, mental load, loss of social support and coping strategies, and financial insecurity contributing to mental ill health. Positive aspects of lockdown were also reported, including a more relaxed pace of life. Conclusions Mental ill health has worsened with the Covid-19 lockdown, particularly in those who are lonely, economically insecure and/or of White British ethnicity. Mental health problems may have longer term consequences for public health. Strategies to mitigate adverse impacts of future lockdowns on mental health should focus on those factors we highlight as associated with worsening mental health.

There is growing concern that the first 'lockdown' measures to control the spread of the Covid-19 pandemic (implemented in the UK between March and June 2020) 1,2 have had unintended consequences including an increase in mental ill health. Several studies since the Covid-19 pandemic began have reported high levels of depression and anxiety 3-7 in the UK. However, the majority of these surveys are either crosssectional or longitudinal within the lockdown period (5) (6) (7) with only two studies (3, 4) comparing mental health in the pre-Covid-19 period to mental health during the March-June 2020 Covid-19 lockdown. One of those used office of national statistics data and found worsening mental health in younger adults, those who were financially insecure or had a disability 3 . The second, using data from two prospective cohorts, found worsening mental health during, compared to before the lockdown in younger adults, women, those with pre-existing mental and physical health conditions, those living alone and in socio-economic adversity 4 . In these studies most participants were of white European origin and the larger of the two studies was in a relatively affluent population. Mental ill health is more prevalent in people from ethnic minorities and the socially and economically disadvantaged 8, 9 , but no longitudinal research to date has investigated the impact of Covid-19 lockdown on mental health in these populations 10 .

We were able to explore these questions in depth by building on the Born in Bradford research programme which includes two longitudinal birth cohorts of ethnically diverse families living in the city of Bradford, many in deprived circumstances. These cohorts have recent in-depth information on the demographics, socioeconomic status and mental health of participants before the Covid-19 pandemic, [11] [12] [13] as well as mental health during the March-June 2020 Covid-19 lockdown 14 , and so offer a unique opportunity to assess the impact of Covid-19 and lockdown longitudinally in a deprived and ethnically diverse population.

We explore the data to:

Describe changes in the prevalence of depression and anxiety in mothers living in Bradford from before the Covid-19 pandemic to during the March-June 2020 Covid-19 lockdown • Identify the variables associated with an increased occurrence of mental ill health in this population, to identify vulnerable groups that may need additional support during subsequent lockdowns.

• To explore mothers' lived experience during the March-June 2020 Covid-19 lockdown by assessing the frequency of worries and concerns relating to mental ill health obtained through free text responses to open questions.

A longitudinal study using data collected at two time points before and during the March-June 2020 Covid-19 lockdown from mothers who participated in one of two prospective birth cohort studies in Bradford: Born in Bradford's Growing Up (BiBGU) study with parents of children currently aged 9-13 11, 12 and Born in Bradford's Better Start (BiBBS) with parents of children currently aged 0-4. 13 

Born in Bradford is a 'people powered' research study; the local community were consulted to identify key research priorities during the March-June 2020 Covid-19 lockdown. This included consultation with key community groups, seldom-heard communities and local policy and decision makers to ensure that the focus of the research was relevant to local needs. The Covid-19 survey and recruitment approach were tested through our established research advisory groups. The findings of the study were also shared with these groups to enhance interpretation and ensure useful dissemination back to the community 14 .

completed over the phone and implied consent was assumed for all questionnaires completed via post or online.

Full details of the data collection and descriptive findings of the March-June 2020 Covid-19 survey can be found elsewhere 14, 15 . In summary:

Pre-Covid-19 data for BiBGU participants were derived from two sources: a) participant ethnicity and age, collected during pregnancy (2007-2011); 11 b) recent follow-up data on mental health (collected between 24 th June 2017 and 12 th March 2020). 12 Pre-Covid data for BiBBS participants were taken from data collected during pregnancy (6 th January 2016 and 8 th February 2020). 13 The median time since most recent pre-Covid data collection was 15 months (range 1 to 35) for BiBGU and 29 months (range 2 to 52) for BiBBS.

March-June 2020 Covid-19 lockdown data collection:

The survey was administered between 10 th April and 30 th June 2020 using a combination of emails, text and phone with a follow-up postal survey. Participants were recruited in their main language wherever possible. Mental health was measured using the PHQ-8 16 for depression and the GAD-7 for anxiety. 17 These are widely used measures of the severity of symptoms of depression and anxiety that have been validated in the general population, 16,17 and in many ethnic minorities including UK residents of Pakistani heritage. 18 Information was also collected on household circumstances; family relationships; social support and loneliness; financial, employment, housing and food insecurity; physical health. This contextual information was captured in self-reported questions administered in the Covid-19 lockdown survey; details of categories used are detailed in Table 1 and our protocol paper 14 . Information on the participants' lived experience during lockdown, including their main worries, challenges and any positive aspects of lockdown were collected using free text questions.

For PHQ-8 and GAD-7 we employed standard categorisations (0 to 4 no depression, 5 to 9 mild depression, 10-24 moderate-severe depression; 0 to 4 no anxiety, 5 to 9 mild anxiety, 10 to 21 moderatesevere anxiety) 16,17 but collapsed moderate, moderately severe and severe categories to indicate clinically important symptoms of depression and anxiety We also used an increase in PHQ-8 and GAD-7 scores of 5 or more points as an indicator of clinically important change in symptoms. This categorisation was chosen following guidance from previous research and consultation with clinical colleagues 19 . An increase of five points or more would also result in a change in the categorization of symptoms (e.g. from none to mild, mild to moderate/severe and vice versa) whilst also capturing changes in severity within the moderate/severe categories.

Ethnicity was coded using Census 2011 categories and categorised as 'White British', 'Pakistani Heritage' and all other ethnic groups were categorised as 'Other' due to small numbers of a wide range of ethnicities.

A number of categories within variables were collapsed for the regression analysis. This included: Quality of relationship with partner: Average to poor (comprising of 'average', 'poor' and 'very poor'); Loneliness: Not lonely (comprising of: 'none or almost none of the time' and 'some of the time') and Lonely (comprising of: 'Most of the time' and 'All or almost all of the time'); Social support: Easy to get support (comprising of: 'Very easy' and 'easy'); and Not easy to get support (comprising of: 'Very difficult', 'Difficult' and 'Possible'); Food insecurity; Secure (Comprising of' never true' or 'sometimes true' that food didn't last) and insecure (Comprising of 'Often true' that food didn't last). Housing security: Secure (Comprising: 'Strongly Disagree', 'Disagree' and 'Neither disagree or agree' that I worry about being evicted or having my home repossessed) and Insecure (comprising of 'Strongly Agree' or 'Agree').

Missing data on measures was small for most variables and was not adjusted for in the analyses. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted November 30, 2020. ; https://doi.org/10.1101/2020.11.30.20239954 doi: medRxiv preprint

We present results of sample characteristics, including depression and anxiety at pre-Covid-19 and Covid-19 lockdown survey time points. We examined change in depression and anxiety categories between pre-Covid-19 and Covid-19 lockdown surveys to elucidate the patterns of both positive and negative changes. We then modelled the odds ratios associated with an increase in PHQ-8 and GAD-7 scores by five or more points (Model 1). We constructed separate unadjusted models for each outcome and covariate of interest, considering variables that were associated with a clinically important increase in mental ill health in the March-June 2020 Covid-19 lockdown survey. 15 Pre-Covid-19 PHQ-8 and GAD-7 scores were controlled for in each model.

In order to explore the association between ethnicity and a clinically important increase in depression and anxiety in more depth, we conducted parsimonious multivariate modelling exercises. Each model controlled for one variable associated with such an increase in model 1.

All statistical analyses were carried out using Stata 15. 20 Free text responses in the survey were coded using thematic analysis. 21 The first 100 responses were analysed by one researcher (BL), employing an inductive approach where coding and theme development were driven by the content of the responses. Two codebooks were developed, one for the questions on the three biggest worries and recent challenges during lockdown and another smaller codebook for the question on what had been made more enjoyable and easier during lockdown. The remaining responses were then coded by three different researchers in order to test the strength and validity of the codebooks. Through frequent discussion between the researchers about this process, adjustments were made to the original codebooks so that they were reflective of the total responses. We also used the emergent themes to illuminate the findings from the quantitative analyses.

This study was approved by the HRA and Bradford/Leeds research ethics committee (Substantial amendments to: BiBGU 16/YH/0320 and BiBBS 15/YH/0455)

Of the 2,043 mothers who responded to the March -June 2020 Covid-19 lockdown survey, 1,860 (91%) had complete surveys and linked data from pre-Covid19 surveys. Of these; 1,316 (71%) were in the BiBGU cohort (with a child aged 9-13) and 544 (29%) were in the BiBBS cohort (with n child aged 0-4). The mothers had a mean age of 37.5 years (SD 6.8). 877 (48%) were of Pakistani heritage, 613 (34%) of White British ethnicity and 320 (18%) of other ethnicities (see Supplemental Table S1 ). Respondents were representative of the BiB and BiBBS cohorts. 15

Moderate / severe depression increased between the pre-Covid-19 and Covid-19 lockdown surveys from 11% (N=212) to 19% (N=349).Rates of mild depression remained similar; while the proportion of those with no depression decreased from 65% (N=1187) to 56% (N=1001), ( Table 1 ). The rates of moderate/severe anxiety increased from 10% (N=167) to 16% (N=289). The prevalence of mild anxiety also increased from 16% (N=270) to 23% (N=408), whilst the proportion of participants with no anxiety fell from 75% (N=1280) to 61% (N=1075), (Table 1) .

[ Table 1 here] Figures 1a and 1b show the change in depression and anxiety categories from the pre-Covid-19 and Covid-19 lockdown surveys. These illustrate that, while rates of depression and anxiety have increased in the study population, some participants' levels of depression and anxiety have improved. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted November 30, 2020. ; https://doi.org/10.1101/2020.11.30.20239954 doi: medRxiv preprint [ Figure 1a &1b here] Table 1 provides the sample characteristics included in the unadjusted regression model. The results from the unadjusted regression models are presented in Table 2 . Variables associated with a clinically important increase in depression and anxiety (reported here in order from the largest to smallest odds ratio) were: Loneliness, financial insecurity, relationship quality, food insecurity, housing insecurity, little or no physical activity, lack of social support, unemployment, poor quality housing, pre-Covid-19 financial security, living in a household with someone clinically vulnerable to Covid-19, being a single parent, and having had to selfisolate. Variables that were not associated with an increase in depression or anxiety were ethnicity, age, being a keyworker, living in a large household and job insecurity.

[ Table 2 here]

The results of a multivariate logistic regression model exploring the relationship between ethnicity, financial insecurity, and increased depression and anxiety can be seen in Table 3 . When financial security is controlled for, we find that Pakistani heritage respondents are less likely to experience an increase in depression and anxiety compared to White British respondents (0.67, 0.51-0.89) and (0.73, 0.55-0.97). All other variables that were associated with an increase in model 1 were tested in similar parsimonious multivariate logistic regression models. When frequency of physical activity was controlled for, Pakistani mothers are again less likely to experience an increase in depression (0.73, 0.56-0.96), but not anxiety (0.81 (0.61-1.07) compared to White British mothers. There were no significant ethnic differences in any of the other models (see supplementary Table S1 -S9).

[ Table 3 here] Free text responses to the question "what are your three biggest worries at the moment" were available for 1799 mothers. Only a small proportion of women identified their mental health issues as one of their biggest worries, N=105 (6%, 95%CI: 5%-7%), slightly greater in White British mothers, N=51 (8%, 95%CI: 6%-11%) than in mothers of Pakistani heritage, N=32 (4%, 95%CI: 3%-5%). More often, mothers reported how wider issues and concerns impacted on their mental health and wellbeing:

Health anxieties about Covid-19: the most commonly reported worry was a fear of bringing the virus home (e.g. from the shops or from their places of work), and themselves or members of their family becoming ill or dying, as well as the fear of what would happen to their children if this did happen to them.

Feeling anxious about the virus and constantly worrying about my kids which 2 of them have health issues and are quite vulnerable I feel particularly anxious to even step out of the house even for food shopping or taking a walk/exercise I worry how this will affect my children. I'm terrified they will be separated as I have 2 children with my exhusband and one with my current. So I haven't been outside in 10 weeks.

Mental load: mothers often reported the mental load of managing work, home-schooling, childcare and domestic tasks, without the break provided by children attending school, nursery or other childcare. Being or feeling stuck inside and unable to move around freely contributed to a sense of suffocation and feeling overwhelmed, and many mothers acknowledged that this was having a detrimental effect on their mental health and self-esteem: is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint 

Loss of social support: The loss of social support caused by lockdown, especially for those who didn't live with their partner or were single parents was highlighted as causing loneliness and isolation for some. Worried about the financial impact of covid 19. I am currently furloughed from work but I worry that the virus will have an impact on the business. My husband is self-employed and is not eligible to any funds.

Being unable to switch off: Participants described being frightened of the news reports but unable to switch off, and were wondering when, if ever, things would become normal again: All the bad news on the TV, and the death rate on the News. All the information on the news makes me panic more.

A loss of coping strategies: For those who had existing mental health issues before lockdown, the lockdown measures had often taken away their sources of support, their normal routines and methods of coping. In addition, some respondents reported being unable to access mental health services due to Covid-19 and lockdown measures: Positive aspects of lockdown: Many participants reported positive aspects to changes enforced by the lockdown, commenting that they were getting to spend more quality time with their children, were enjoying a slower pace of life, a more relaxed routine and spending less time driving and commuting. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted November 30, 2020. ; https://doi.org/10.1101/2020.11.30.20239954 doi: medRxiv preprint Life has become a lot more relaxed over the last 3 weeks, no manic mornings trying to get everybody out of the house, time with kids, doing stuff with kids I would normally say 'not now' to. Get to know kids more. More time outside, [doing] jobs in the house that need doing.

Ramadan is the easiest it has ever been, we are free to make up our sleep and not push ourselves too much, had time to do nice things during Ramadan including having a more peaceful time not having to do school runs, be stressed out, my husband had a chance to take a slower pace to life and not get too stressed.

We compared depression and anxiety during the March-June 2020 UK lockdown to pre-Covid19 depression and anxiety data collected in our longitudinal birth cohort studies. We found that clinically important symptoms of depression and anxiety increased from 11% to 19% and from 11% to 16%, respectively. The variables that were most strongly associated with a clinically important increase in depression and anxiety from pre-Covid19 to the March-June 2020 lockdown were loneliness and financial, insecurity. The prevalence of these key variables was high in our families, highlighting the vulnerabilities and risk of poorer outcomes from the Covid-19 pandemic in ethnically diverse and deprived families. White British mothers were found to be more likely to have an increase in depression and anxiety symptoms when variation in financial insecurity was controlled for. White British mothers were also more likely to have an increase in depression but not anxiety when levels of physical activity was controlled for. The free text responses in our Covid-19 lockdown survey allowed us to explore the specificities of poor mental health in more detail highlighting: acute health anxieties; the mental load of managing multiple roles and responsibilities; the loss of social support and other coping strategies; pressures of financial and employment insecurity; and being unable to switch off from the pandemic. These responses highlight the complexities of how the March-June 2020 lockdown may have impacted on mental health, and also how some of the positive experiences may have protected some mothers from mental ill health at this time.

This is a longitudinal study containing linked data collected before the Covid-19 pandemic and at the beginning of the March-June 2020 lockdown which has allowed us to explore change over that time period. It also provides findings from a highly ethnically diverse population, the majority of whom live in the most deprived centiles in the UK. We are not aware of other studies that have explored longitudinal change in mental health from pre-to during-the Covid-19 lock down in a similar ethnically diverse deprived population Respondents were mothers of children aged 0-5 and/or 9-13 which may limit the wider generalizability, though our findings are broadly similar to those from a previous longitudinal study of two UKC cohorts that included adult men and women (not all of whom were mothers), and found the increased risk of poor mental health in lockdown to be greater in women 4 . Our pre-COVID19 measures were taken from data collected over the past 4 years, so we cannot with confidence attribute all changes to the pandemic and the lockdown. For example, it is possible that some of the difference reflects age related change in the women and/or their children over time. It is also possible that we have underestimated some of the adverse impact of lockdown as a significant percentage of the participants were pregnant at baseline, which itself is associated with raised levels of depression. However, the deterioration in mental health is large and is similar to that of the ONS study which found that depressive symptoms in the general population of the UK doubled to 19.6% in June 2020 compared to the same time period in 2019. 3 It is possible that our results are influenced by selection bias given that 28% of those invited to participate in the Covid-19 survey responded. However these participants were representative of the BiB and BiBBS cohorts 15 , and have demonstrated a wide variability in most characteristics (Table 1) .

We will continue to follow our families over time so that we can look at trajectories of change overtime, including during any future national or regional lockdowns. At time of writing (November 2020), the UK is under a further nation-wide lockdown, following a period of reduced restrictions during summer 2020 and is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted November 30, 2020. ; https://doi.org/10.1101/2020.11.30.20239954 doi: medRxiv preprint tighter regional restrictions in the more deprived cities of Northern England, including Bradford, though the autumn. The impact of further and longer periods of restrictions and lockdowns will be a focus of our study moving forwards.

The increase in depression and anxiety in White British mothers relative to Pakistani mothers, once financial insecurity and physical activity were controlled, is of interest. Financial insecurity and low levels of physical activity are higher in our Pakistani families, but the resilience to mental ill health appears to be greater in Pakistani mothers compared to White British mothers once these variables are accounted for. We have previously reported that White British mothers are more likely to have their mental ill health identified by health professionals than South Asian women but that both White British and South Asian women are equally likely to disclose symptoms in self-report research questionnaires as used here. 22,23 It is possible that differences in family structure and culture might provide more support in times of adversity, as we have found in the case of food insecurity previously 24,25 . This hypothesis warrants further investigation, and longitudinal qualitative research would add real depth to understanding this difference.

Our results highlight the public health impact of lockdown on mental health, particularly in those who are lonely and economically insecure and of White British ethnicity. Mental health problems are in general less visible than physical symptoms and in particular the physical symptoms related to Covid-19, including the acutely ill patients in ICUs, but may have more significant longer-term consequences.

Government and local councils should consider policies that permit 'social bubbles' that can be implemented to reduce loneliness for those at risk, and for voluntary services to continue to focus support to those who are lonely/isolated. Policy and decision makers should also make provision for the continuing need to support and protect vulnerable families from financial, food and housing insecurity, all of which were associated with poor mental health in this study. These actions will be increasingly important through further regional and national lockdowns.

The findings of the study were also shared with our community research advisory groups to enhance interpretation. We will share our findings with all participants using a combination of social media, infographics posted to participants and community dissemination events

Born in Bradford offer open access to their data resources. Available data and procedures to access this can be found at: https://borninbradford.nhs.uk/research/how-to-access-data/_

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: all authors had financial support from funding bodies listed below for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

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The lead author (the manuscript's guarantor) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as originally planned (and, if relevant, registered) have been explained. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

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. CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted November 30, 2020. ; https://doi.org/10.1101/2020.11.30.20239954 doi: medRxiv preprint 

. CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted November 30, 2020. ; https://doi.org/10.1101/2020.11.30.20239954 doi: medRxiv preprint Anxiety category at pre-Covid19 survey (from GAD7 score) None (GAD-7 score 0 to 4) 1280 75% (72%-77%) Mild (GAD-7 score 5 to 9) 270 16% (14%-18%) Moderate (GAD-7 score 10 to 14) 100 6% (5%-7%) Severe (GAD-7 score 15 to 21) 67 4% (3%-5%) Missing 143 Total 1860 100%

Anxiety category at lockdown survey (from GAD7 score) None (GAD-7 score 0 to 4) 1075 61% (58%-63%) Mild (GAD-7 score 5 to 9) 408 23% (21%-25%) Moderate (GAD-7 score 10 to 14) 165 9% (8%-11%) Severe (GAD-7 is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

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The copyright holder for this this version posted November 30, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted November 30, 2020. ; https://doi.org/10.1101/2020.11.30.20239954 doi: medRxiv preprint Models also controls for baseline PHQ-8 score Models also controls for baseline GAD-7 score . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted November 30, 2020. ; https://doi.org/10.1101/2020.11.30.20239954 doi: medRxiv preprint

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ACKNOWLEDGEMENTS Born in Bradford is only possible because of the enthusiasm and commitment of the children and parents in BiB. We are grateful to all the participants, health professionals and researchers who have made Born in Bradford happen.