key: cord-1006077-wzodz59r authors: Liu, Yixiu; Li, Lei; Jiang, Xingmei; Liu, Yihao; Xue, Rui; Yu, Hua; Wei, Wei; Meng, Yajing; Li, Zhe title: Mental state, biological rhythm and social support among healthcare workers during the early stages of the COVID-19 epidemic in Wuhan date: 2022-05-14 journal: Heliyon DOI: 10.1016/j.heliyon.2022.e09439 sha: 42fae727e0740f199110aaa7a8c4aa69d8bf2ea3 doc_id: 1006077 cord_uid: wzodz59r BACKGROUND: The COVID-19 pandemic has put the mental health of healthcare workers at risk. However, the potential psychosocial factors underlying mental health problems, such as depression and anxiety, require further investigation. The present study aimed to explore the factors that influence the mental state of healthcare workers. METHODS: A total of 276 healthcare workers completed a set of online self-report questionnaires from February 2 to 5, 2020, in the following order: general information related to the COVID-19 outbreak, Biological Rhythms Interview of Assessment in Neuropsychiatry, Beck Depression Inventory-II, Beck Anxiety Inventory, and Social Support Rating Scale. RESULTS: Our study revealed that both social support and age moderated the ability of biological rhythm disturbance to exacerbate depression (R(2) = 0.47; effect size f(2) = 0.85). Higher levels of social support buffered the amplification of depression associated with increased biological rhythm disturbance in all age groups, and especially in younger individuals (mean age = 26.57, se = 0.04). Depressive symptoms were predicted by both social and sleeping rhythms, whereas anxiety symptoms were predicted only by social rhythm. Married individuals had lower biological rhythm disturbance ratings and higher social support ratings. Females also reported higher ratings in social support. CONCLUSIONS: Our study suggests that biological rhythm intervention along with social support can reduce the negative effect of biological rhythm disturbance on mood disorders, especially in younger people. We also provide evidence for the ability of social support to buffer stress in a major health crisis and demonstrate the effects of marital status and sex, which provide a different perspective for studying mental crisis management. Since the outbreak of the COVID-19 pandemic, the majority of the world's health 64 services have taken on serious responsibilities 1 and the crisis management approach to 65 mental health has come under the spotlight 2, 3 . Recent studies have shown that more 66 than 36.9% of healthcare workers in Wuhan, China have experienced subthreshold 67 mental health disturbance, among which 6.2% have experienced severe disturbance 4 , 68 50.4% depression, 44.6% anxiety, and 34.0% insomnia 5 . However, little is understood 69 about the psychosocial processes underlying these mental disorders. 70 A potential psychosocial mechanism causing these disorders is the intense workload 71 of healthcare staff that disturbs their biological rhythms, especially sleeping, appetite, 72 and patterns of social interaction 6 . Empirical studies have shown that low-quality sleep 73 leads to depression and anxiety 7, 8 , which could explain the increased prevalence of 74 mood disorders during the COVID-19 pandemic 5 . Moreover, the effects of poor sleep 75 on mood disorders are influenced by individual factors, such as age 9 . However, there is 76 limited research on biological rhythm disturbance in different age groups of healthcare 77 workers during the current pandemic. 78 Another potential factor affecting the development of mood disorders is the limited 79 social support available to healthcare workers during the pandemic. Social support 80 refers to support measures that are accessible to individuals through their social 81 relationships with other people, groups, and the wider community 10, 11 , and that can be 82 divided into objective support, subjective support, and utilisation of support 12 . Early 83 empirical studies have shown that depression and anxiety are negatively associated with 84 social support 13,14 , especially subjective support 15 . A study also reported that social 85 support available to healthcare workers during the pandemic was negatively associated 86 with depression and anxiety 16 . 87 Social support can reduce the impact of stressful or negative events on depression, 88 as strong social relationships help individuals cope with stress, a process also known as 89 the stress buffering effect 17, 18 . Empirical studies have led to numerous models that 90 explore the ability of social support to buffer effects of stress-related depression 19-21 91 and stressful or negative life events 22 across various age groups. Additional studies have 92 shown that stress caused by negative life events might be caused by the disturbance of 93 social rhythm 23, 24 . As a sub-factor of biological rhythm, the social rhythm of healthcare 94 workers is also severely affected by the pandemic due to various stressors, such as the 95 J o u r n a l P r e -p r o o f mandatory quarantine. Therefore, even limited social support is likely to exert a 96 buffering effect in the pandemic similar to that reported in previous studies [19] [20] [21] [22] . 97 However, the COVID-19 pandemic differs from other stressful incidents, such as 98 pregnancy, so the role of social support requires further investigation. 99 During the pandemic, each healthcare worker may have access to different levels of 100 social support, as some people may have closer relationships (e.g., marriage) than 101 others. Accordingly, social support can be divided into three components 25 : the social 102 support which objectively presents in one's relationships, or objective support; the 103 support one perceives to be available, or subjective support; and how much social 104 support one actually uses, or utilisation of support. Whether social support is sensitive 105 to such differences among workers is unclear. In the present study, we aimed to investigate the psychosocial processes underlying 107 depression and anxiety among healthcare workers during the COVID-19 pandemic. First, we compared the consistency of our results for depression and anxiety with 109 previous studies. Second, we explored whether biological rhythm and social support 110 sub-factors could serve as predictors of depression and anxiety, and we hypothesized 111 that sleeping rhythm and subjective social support would be the most significant 112 predictors. Finally, we tested whether social support can buffer the ability of biological 113 rhythm disturbance to amplify mood disorders in different age groups. 135 To ensure data quality, each IP address was allowed to submit only one set of survey 136 responses. (Table 1) . 199 As shown in Figure 2 , the feeding subscale of BRIAN was lower in the unmarried group 205 The correlation matrix of social support subscales, depression level, anxiety level, and 206 sample age (Table 2) showed that healthcare workers with greater access to overall 207 social support were less likely to report depressive symptoms (rs = −0.25, ps < 0.001), 208 but no significant correlation was found between social support and anxiety (rs = −0.10, 209 ps = 0.088). 211 The correlation matrix of BRIAN subscales, depression, level, anxiety level, and 212 sample age (Table 3) showed that overall BRIAN score positively correlated with 213 depression (rs = 0.63, ps < 0.001) and anxiety (rs = 0.52, ps < 0.001). 215 To identify potential predictors of depression, SSRS subscales were entered into linear 216 regression analysis, which showed that depression could be predicted by subjective 217 support (β = −0.30, t = −5.19, p < 0.001) (Table 1) . Similarly, BRIAN subscales were 218 J o u r n a l P r e -p r o o f entered into linear regression analysis, which indicated that depression could be 219 predicted by social rhythm (β = 2.03, t = 13.46, p < 0.001) and sleeping rhythm (β = 220 1.24, t = 9.67, p < 0.001) ( Table 2) , while anxiety could be predicted only by social 221 rhythm (β = 0.24, t = 9.70, p < 0.001) ( Table 3) Table 230 4 ). BRIAN subscales were entered into linear regression analysis to determine the 232 predictor(s) of depression and anxiety. As shown in Table 5 , depression was predicted 233 by the social rhythm (β= 2.03, t=13.46, p<.001) and sleeping rhythm (β=1.24, t=9.67, 234 p<.001). Anxiety was predicted by social rhythm (β=.24, t=9.70, p<.001; Table 6 ). buffering effect among the three tested groups, and the effect was again higher in the 247 young age group (β = 0.62, se = 0.05, t = 11.97, p < 0.001) than in the middle age (β = 248 0.50, se = 0.05, t = 11.11, p < 0.001) and old age groups (β = 0.38, se = 0.06, t = 6.26, 249 p < 0.001) ( Figure 3C ). Low social support was also associated with the highest relative 250 overall depression score. The present study explored the differences in biological rhythms and social support and 253 their association with depression and anxiety among healthcare workers during the 254 early stages of the COVID-19 epidemic. Our results showed that the overall SSRS 255 negatively correlated with depression but not with anxiety, partially consistent with the 256 results of a recent study 16 . We also found that subjective support positively correlated 257 with age and could be therefore used to predict depression. Social support and 258 utilisation of support were sensitive to marital status, with unmarried healthcare 259 workers (single, divorced and widowed) receiving less social support than married ones. In contrast to a recent study 38 , we found that activity or feeding rhythms cannot 286 predict depressive symptoms. The feeding rhythm is considered a "zeitgeber" (timer) 287 for the regulation of the circadian clock, as the molecules generated by biochemical 288 reactions during a meal regulate other biological rhythms 42 . Thus, delaying a meal 289 could lead to metabolic syndrome due to chrono-disruption 43 The buffering effect of all levels of social support was stronger in the younger age The present study was an exploratory cross-sectional study and did not compare Berkman LF, Glass T. Social integration, social networks, social support, and health. 387 J o u r n a l P r e -p r o o f Beck depression inventory-II. Psychological 433 Assessment Psychometric properties and 435 measurement equivalence of the English and Chinese versions of the Beck Anxiety Inventory 436 in patients with breast cancer Theoretical basis and application in research of social support rating scale Sleep and circadian rhythm in response 443 to the COVID-19 pandemic Clinical evaluation of biological rhythm domains in patients with 445 major depression Circadian rhythm disturbances in depression Negative life events, social support and 449 gender difference in depression. Social psychiatry and psychiatric epidemiology Gender Differences in the Rates of Exposure 452 to Stressful Life Events and Sensitivity to Their Depressogenic Effects Mood disorders and 455 biological rhythms in young adults: A large population-based study Social functioning in major depressive disorder Social functioning in depression: 460 a review How might circadian rhythms control mood? Let me count the ways The bipolarity of light and dark: A review on Bipolar Disorder 464 andcircadian cycles Does human evolution in different latitudes influence susceptibility to obesity 466 via the circadian pacemaker? Migration and survival of the fittest in the modern age of lifestyle-467 induced circadian desynchrony Treating depression with 469 physical activity in adolescents and young adults: a systematic review and meta-analysis of 470 randomised controlled trials Sadness 0. I do not feel sad I feel sad much of the time I am so sad or unhappy that I can't stand it. 2. Pessimism 0. I am not discouraged about my future I feel more discouraged about my future than I used to I do not expect things to work out for me I feel my future is hopeless and will only get worse Past Failure 0. I do not feel like a failure I have failed more than I should have As I look back, I see a lot of failures I get as much pleasure as I ever did from the things I enjoy I don't enjoy things as much as I used to I get very little pleasure from the things I used to enjoy I can't get any pleasure from the things I used to enjoy Guilty Feelings 0. I don't feel particularly guilty I feel guilty over many things I have done or should have done. 2. I feel quite guilty most of the time Punishment Feelings 0. I don't feel I am being punished I feel I may be punished I feel I am being punished Self-Dislike 0. I feel the same about myself as ever I have lost confidence in myself I am disappointed in myself Self-Criticalness 0. I don't criticize or blame myself more than usual I am more critical of myself than I used to be I criticize myself for all of my faults I blame myself for everything bad that happens Suicidal Thoughts or Wishes 0. I don't have any thoughts of killing myself I have thoughts of killing myself, but I would not carry them out. 2. I would like to kill myself I would kill myself if I had the chance. 10. Crying 0. I don't cry anymore than I used to I cry more than I used to I cry over every little thing I feel like crying, but I can't I am no more restless or wound up than usual I feel more restless or wound up than usual I am so restless or agitated, it's hard to stay still I am so restless or agitated that I have to keep moving or doing something Loss of Interest 0. I have not lost interest in other people or activities I am less interested in other people or things than before I have lost most of my interest in other people or things It's hard to get interested in anything. 13. Indecisiveness 0. I make decisions about as well as ever I find it more difficult to make decisions than usual I have much greater difficulty in making decisions than I used to I have trouble making any decisions. 14. Worthlessness 0. I do not feel I am worthless I don't consider myself as worthwhile and useful as I used to I feel more worthless as compared to others Loss of Energy 0. I have as much energy as ever I have less energy than I used to have I don't have enough energy to do very much I don't have enough energy to do anything Changes in Sleeping Pattern 0. I have not experienced any change in my sleeping. 1a I sleep somewhat more than usual. 1b I sleep somewhat less than usual. 2a I sleep a lot more than usual. 2b I sleep a lot less than usual. 3a I sleep most of the day. 3b I wake up 1-2 hours early and can't get back to sleep I am much more irritable than usual Changes in Appetite 0. I have not experienced any change in my appetite. 1a My appetite is somewhat less than usual. 1b My appetite is somewhat greater than usual. 2a My appetite is much less than before. 2b My appetite is much greater than usual. 3a I have no appetite at all. 3b I crave food all the time Concentration Difficulty 0. I can concentrate as well as ever It's hard to keep my mind on anything for very long I find I can't concentrate on anything Tiredness or Fatigue 0. I am no more tired or fatigued than usual I get more tired or fatigued more easily than usual I am too tired or fatigued to do a lot of the things I used to do I am too tired or fatigued to do most of the things I used to do Loss of Interest in Sex 0. I have not noticed any recent change in my interest in sex I am less interested in sex than I used to be I am much less interested in sex now I have lost interest in sex completely How many friends do you have that are close enough to get support and help: (Choose only one item Living away from your family members and in a house by yourself Your living place changes frequently and you live with strangers most of the time Living with classmates, colleagues or friends How do you get along with your neighbors: (Choose only one item) Never cared for each other, just nodding acquaintance May be slightly cared when you encounter problems How do you get along with your colleagues: (Choose only one item) Never cared for each other, just nodding acquaintance May be slightly cared when you encounter problems The sources of financial support and help which solve practical problems in the past when you were in emergency situations are No source at all The following sources: (You can choose more than one) A. Spouse; B. Other family members Official or semi-official organizations such as parties and unions Unofficial organizations such as religious and social groups No source at all The following sources: (You can choose more than one) A. Spouse; B. Other family members Official or semi-official organizations such as parties and unions Unofficial organizations such as religious and social groups Never talk to anyone When friends ask, you will talk Initiatively talk about your worries in order to get support and understanding How do you seek for help when in troubles: (Choose only one item) Only rely on yourself and refuse help from others Always ask for help from family members, relatives, and organizations when in trouble Activities organized by groups (such as party and group organizations, religious organizations, labor unions, student unions, etc.): (Choose only one item) Never participate Occasionally participate