key: cord-1023858-tso7m1ai
authors: Garcia-Priego, B. A.; Triana-Romero, A.; Pinto-Galvez, S. M.; Duran-Ramos, C.; Salas-Nolasco, O.; Manriquez Reyes, M.; Ramos de la Medina, A.; Troche, J. M. R.
title: Anxiety, depression, attitudes, and internet addiction during the initial phase of the 2019 coronavirus disease (COVID-19) epidemic: A cross-sectional study in Mexico.
date: 2020-05-15
journal: nan
DOI: 10.1101/2020.05.10.20095844
sha: c909ec440809095e4c1ce74a6fa5b195def29e11
doc_id: 1023858
cord_uid: tso7m1ai

Abstract Objectives: To describe the prevalence and distribution of anxiety and depression among Mexican population, and to examine its association with internet addiction during the COVID-19 outbreak. Design: A web-based cross-sectional study. Setting: General population in Mexico. Participants: 561 subjects were recruited (71% female, mean age of was 30.7 {+/-} 10.6 years). Interventions: An online survey to assess personal attitudes and perceptions towards COVID-19, sleep-disorders related, the Mexican version of the Hospital Anxiety and Depression Scale (HADS) and the Internet Addiction Test (IAT) was applied. Primary and secondary outcome measures: Prevalence of anxiety, depression, internet addiction and sleep disorders and associated factors. Also, prevalence for anxiety and depression were compared to an historic control group. Results: During the initial phase of the COVID-19 pandemic the prevalence for anxiety and depression was 50% (95% CI, 45.6% to 54.1%) and 27.6%, (95% CI 23.8% to 31.4%), respectively. We found a 51% (33% to 50%) increase in anxiety and up to 86% increase in depression uring the initial weeks of the lock-down compared to the control group. According to the IAT questionnaire, 62.7% (95% CI 58.6% to 68.8%) of our population had some degree of internet addiction. Odds ratio for development of anxiety symptoms was 2.02 (95% CI1.56-2.1, p=0.0001) and for depression was 2.15 (95% CI 1.59-2.9, p=0.0001). In the multivariate analysis, younger age (p=0.006), sleep problems (p=0.000), and internet addiction ( p=0.000) were associated with anxiety and depression. Conclusions: Our study provides valuable information on the psychological impact that the COVID-19 pandemic has had on the Mexican population. As in other parts of the globe, in Mexico, fear of SARS-CoV-2 infection has had devastating consequences on mental health, such as anxiety, depression and sleeping disturbances. Internet abuse and the consequent overexposure to rapidly spreading misinformation (infodemia) are associated to anxiety and depression.

In early December 2019, the first cases of an unknown type of pneumonia in humans were reported in Wuhan City, Hubei Province, China. 1 The World Health Organization (WHO) working along with the Chinese authorities identified the etiological agent as a new type of coronavirus which was first named novel coronavirus (nCoV-2019) and finally severe acute respiratory syndrome coronavirus (SARS-CoV-2). 2 Over a period of a few weeks, the infection spread across the globe at rapid pace and on January 30 th , the WHO declared a public health emergency of international concern. 3 On February 11st, 2020 the novel virus disease was named Coronavirus Disease -19 or "COVID-19". On March 11 th , COVID-19 was declared a pandemic. 4 COVID-19 has been since its origins a highly contagious disease, the virus spread rapidly across the planet, and by early May 2020 it had infected more than 3.3 million people in 187 countries.. 5 Due to its high infection rate, lethality and lack of previous immunity, this novel infection has been perceived as a major threat to the life and health of the global human population.

The first case of COVID-19 in Latin America was reported in Brazil on February 26th, 2020, and the first death on March 7th in Argentina. 6 In Mexico, the first case was reported on February 25 th and the first death on March 18 th . 8 Mexico is the 13th-largest country in the world in size and the 10 th most populous with 128,649,565 inhabitants. 7 The Mexican government declared a national health emergency on March 30th and implemented restrictions in the public, private, and social sectors which include: voluntary . CC-BY-NC-ND 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 May 15, 2020. . https://doi.org/10.1101/2020.05. 10.20095844 doi: medRxiv preprint quarantine (lock-down), school closings, social distancing, and limitation of non-essential activities. 9 As in other parts of the globe, life in Mexico has dramatically changed at many different levels and fields: family, science, medicine, economics, religion, culture, human behavior, and technology. 10 It's known that both massive tragedies and global disease outbreaks (like COVID-19) have a negative impact on mental health. Previous studies have established a clear link between pandemic and symptoms of stress, depression, anxiety, post-traumatic stress, and suicidal tendencies. [10] [11] [12] According to the behavioral immune system (BIS) theory, personal reactions to the COVID-19 pandemic, include the development of self-protection mechanisms, such as fear, negative emotions, and negative cognitive evaluation. 13 In addition to the fear and anxiety caused by the virus itself, several other factors may negatively impact the mental health of people under lock-down. 14, 15 The internet has become an essential and inseparable part of the modern lifestyle. 16 However, there is a "problematic behavior of human interactions with information and communication technologies" that has led to the development of concerning long-term issues. 17 The term "internet addiction," which is defined as "a psychological dependence on the internet, regardless of the type of activity once logged on," describes this problematic behavior. 18 Several studies have found that internet addiction increases the risk of depression, anxiety and stress. [16] [17] [18] [19] Due to the sudden onset of COVID-19, few studies have explored the effects of SARS-COV-2 on mental health. 14, 20, 21 To our knowledge there are no studies in Latin American countries that have explored how this pandemic may increase internet addiction, . CC-BY-NC-ND 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 May 15, 2020. . https://doi.org/10.1101/2020.05. 10.20095844 doi: medRxiv preprint and its relationship to triggering anxiety and depression in the general population. We believe that a comprehensive management of the pandemic is essential, not only focusing on the physical aspects and infected patients, but also on mental health , which can be directly reflected in ideas, emotions, and cognition.

Our study aims to describe the prevalence and distribution of anxiety and depression among Mexican population, and to examine its association with internet addiction during the COVID-19 outbreak, using a rapid internet-based assessment.

A cross-sectional study was conducted online from March 23 th to April 21th, 2020, when increased numbers of COVID-19 cases were identified, along with an increased potential for person-to-person transmission in Mexico (phase 2). Mexican citizens aged > 18 years old were invited to participate in an online survey using the Google Forms software. The link to the questionnaire was sent through email and social media. The participants were encouraged to roll out the survey to as many people as possible (snowball sampling),thus the link was forwarded to people apart from the first point of contact and so on. Upon receiving and clicking the link, participants got auto directed to information on the study and informed consent.

The online survey included 30 items, divided into five categories: a) demographic data (age, gender, state of origin, comorbidities, previous diagnosis of anxiety and depression), b) personal attitudes and perceptions towards COVID-19 (beliefs, level of trust . CC-BY-NC-ND 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 May 15, 2020. . https://doi.org/10.1101/2020.05. 10.20095844 doi: medRxiv preprint in prevention recommendations, symptoms, and when to search medical care), c) sleepdisorders related questions, d) the Mexican version of the Hospital Anxiety and Depression Scale (HADS) 22, 23 and finally, e) the Internet Addiction Test (IAT). 24 Subjects with a previous diagnosis (in the past 3 months) of anxiety and depression were excluded.

HADS has been widely used because its good performance in identifying caseness and assessing symptom severity for anxiety disorders and depression in somatic, psychiatric, and primary care patients, and in the general population. HADS has been validated in Spanish for the Mexican population. 22 indicating the presence ("caseness") of a mood disorder, and a score of 8-10 being just suggestive of the presence of the respective state. 22 As proposed by others, we considered a score of ≥ 8 as positive for either anxiety or depression symptoms. 25 The sensitivity and specificity of HADS-A and HADS-D with a threshold of 8+ is often found to be in the range of 0.70 to 0.90 with areas under the curve (AUC) of 0.84 -0.96. 22 The IAT Spanish version is a 20-item scale that measures the presence and severity of internet dependency among adults, 26 each item consists of a Likert-scale with a range of 0 to 5. According to the score at the end of the test, patients can be classified into four categories: 0 to 19 can be considered as absence of addiction, 20 to 39 indicates a low level of addiction and average online user, 40 to 69 a moderate level of addiction, and a score ≥ 70 a severe level of internet addiction. 24, 26 . CC-BY-NC-ND 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 May 15, 2020. 

Data were protected according to the General Data Protection Regulation. The text message bearing the link to the Google Form which was shared with the participants contained information on the title and aim of the study, the eligibility of participants, information on the benefits and harm, and the average duration required to fill a questionnaire which was 3 min. This information was also found on the first page of the Google Form and participants were given the option to either consent to participate (which will give them access to the questionnaire) or decline to participate (which will automatically submit a blank form).

Biological Research Institute (IIIMB-UV#2020-01-005).

Descriptive statistics have been used in this study to analyze the findings. Mean and standard deviation and proportions have been used to estimate the results of the study. The χ 2 /trend tests were used to determine the prevalence of depression, anxiety, and combination of depression and anxiety by categorical variables including social internet addiction and sleep problems. Multivariate logistic analysis regression was used to explain the association between the prevalence of depression, anxiety, and internet addiction. We estimated the adjusted ORs and their 95% confidence intervals (CIs) of independent variables for frailty. The IBM SPSS version 24 (IBM, Chicago, Illinois, US) was used to carry out all analyses.

As a control group, to compare anxiety and depression symptoms, we used data from 458 subjects (62% female, mean age 29.8 ± 8.6 years) to whom the same . CC-BY-NC-ND 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 May 15, 2020. . https://doi.org/10.1101/2020.05. 10.20095844 doi: medRxiv preprint questionnaires for anxiety and depression were applied between September 2019 and January 2020. These subjects come from a study of prevalence of anxiety and depression in open population that is ongoing in our country as part of a screening program for metabolic syndrome and non-alcoholic fatty liver disease.

We received responses from 593 participants, 22 were excluded because reported a previous anxiety or depression diagnosis. Thus, 561 subjects were analyzed, 400 were female (71%), and the mean age was 30.7 ± 10.6 years. There were respondents from 25 out of the 32 states that constitute México. All respondents were from urban areas.

Most of the participants (99.6%) were aware of the pandemia and consider SARS-COV2 as a real threaten to their health. Eighty two percent (n=459) perceive themselves at risk to get infected and develop COVID-19 during the following months. Most (98%) of the participants thought social distancing was essential to stop the virus from spreading.

Most participants (97 %) acknowledged that washing hands frequently could stop the spread of infection. Figure 1 shows what would be the behavior of subjects in case of acquiring COVID-19. Although 82% of respondents would attend ER if presenting alarm signs, 14% will attend as soon if they had the first symptom that for them was suspicious for COVID-19. Most of the respondents will accept hospitalization and all required measures (95%, n=532) in case of a complicated clinical course; 5% (n=29) then, consider that there are no useful treatments for severe cases and fatality is inevitably highly. One hundred and eighty-. CC-BY-NC-ND 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 May 15, 2020. . https://doi.org/10.1101/2020.05. 10.20095844 doi: medRxiv preprint one (33%) consider that the fear and worries related to COVID-19 has interfered with the quality of their sleep (Figure 2 ).

Two hundred and eighty subjects (50%; 95% CI, 45.6% to 54.1%) have developed anxiety symptoms during the COVID-19 breakout (Figure 3) 

According to the IAT questionnaire, 352 (62.7%, 95% CI, 58.6% to 68.8%) of our surveyed population had some degree of internet addiction: 293 (52.2%, 95% CI 48.0% to 64.8%) low, 57 (10.2%, 95% CI 7.5% to 12.7% ) moderate and 2 (0.4%, 95% CI 0.04% to 1.2% ) severe addiction. Subjects with internet addiction were younger and had higher scores for anxiety and depression (Table 1) . Also, prevalence for anxiety, depression and sleep disturbance were higher in subjects with higher levels of internet addiction ( Table 1) .

As is shown in Figure 3 , compared to the control group, the prevalence for anxiety, depression and internet addiction was significantly higher in the participants that were evaluated during the initial phase of the COVID-9 pandemic. Odds ratio for development of . CC-BY-NC-ND 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 May 15, 2020. 

. CC-BY-NC-ND 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. cases, anxiety and depression significantly increased in Mexico. To assess this situation we used HADS because it's validated in Spanish and performs well in screening the caseness and different dimensions of anxiety and depression among non-psychiatric hospital patients as well as in the general population. 25 We found a 51% (33% to 50%) increase in anxiety symptoms (HAD-A >8) and up to 86% (15% to 28%) increase in depression symptoms (HAD-D >8) during the initial weeks of the lock-down compared to the control group. If we consider a cut-off value of >11, the increase in anxiety disorders was 81% (15% to 29%) and 266% in depression (3% to 11%).

The last national mental health survey conducted in Mexico, showed that the overall prevalence for anxiety disorders was 14.3%, 35 and that 4.5% of the population may suffer . CC-BY-NC-ND 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 May 15, 2020. . https://doi.org/10.1101/2020.05.10.20095844 doi: medRxiv preprint from some mood disorder, including depression. These percentages are similar to those found in our control group (15% and 3% respectively), thus, we believe that the increase we are reporting in anxiety and depression is real and reflects how the COVID-19 pandemic triggers anxiety and depression in our population. This is an important and remarkable finding considering that the knowledge and attitude towards COVID-19 in our population was high in terms of awareness of the disease, and measures to avoid infection such as social distancing and washing hands.

Our results are consistent with those reported in other populations during the outbreak. Wang et al., 21 in a study that included 1210 respondents from 194 cities in China, found that 53.8% of respondents rated the psychological impact of the outbreak as moderate or severe; 16.5% reported moderate to severe depressive symptoms, and 28.8% Several factors have been associated to anxiety and depression during the COVID-19 pandemic in other countries such as: female gender, student status, poor self-rated health status and frequent social media exposition. In our study, using the IAT ( a specific tool to assess internet dependency), we found that low to mild levels of internet addiction were highly prevalent (62%) and correlated to anxiety and depression. 14, 21, 36 To our knowledge, this is a novel finding not previously reported. Gao et al, 14 found that during the pandemic, 82.0% of the Chinese population was frequently expose to social media. Internet . CC-BY-NC-ND 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 May 15, 2020. . https://doi.org/10.1101/2020.05. 10.20095844 doi: medRxiv preprint abuse is very likely to be associated with overexposure to rapidly spreading misinformation (infodemia) and unfounded fears due to the fact that people constantly express their negative feelings, worries, and anxiety on social media, which may have a contagious effect. Overuse of internet to obtain information about COVID-19 may exacerbate stress responses, increase levels of anxiety and depression, amplify concern, and impair functioning. This can lead to additional media consumption and further distress, creating a cycle that can be difficult to break. 37 According to our results internet abuse was also associated to sleep problems and younger age. Roy et al, 20 found that, in Indian population, sleep difficulties, paranoia about acquiring COVID-19 infection and distress related to social media use were reported in 12.5 %, 37.8 %, and 36.4 % participants, respectively. The negative impact of internet abuse on both sleep duration and sleep quality has been previously described in the literature. 38 For example, Kim et al 39 found that Korean subjects with internet addiction were 1.7 times more likely to experience poor sleep quality in comparison to those with normal internet use. Also, subjects who spent more time in the web have more (2.5 times higher) risk of developing depressive symptoms. Our results are also consistent with previous reports that the younger generations trend to be heavier internet users and are more exposed to social media exposition than older people. 40 The reasons are multiple but mainly involve technical skills and availability of internet resources.

An important factor associated to anxiety and depression in our study was younger age. This is a surprising finding considering that young people are considered a low risk group for complications and mortality associated with SARS-CoV-2. It has even been described that the possibility of being an asymptomatic carrier of the virus is greater in young people than in older subjects. 41 One explanation is that younger generations, who are . CC-BY-NC-ND 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 May 15, 2020. . https://doi.org/10.1101/2020.05. 10.20095844 doi: medRxiv preprint at home as consequence of the COVID-19 outbreak, may be experiencing stressful situations to which they have never been exposed before, such as changes in their routines, uncertainty, concern for their health and insecurities about the impact and duration of the disease. The lack of social interaction has caused an increase in mental health problems as well. Panic, stress, anxiety, depression, boredom, anger, suicidal ideation, and sleep disturbances have also been reported as a consequence of social isolation. 42, 43 In addition, staying home for long periods of time can lead to receiving less sunlight, which could decrease serotonin levels. This has been associated with emotional disorders like anxiety but mainly depression. 44 As in other studies, we found that women were more likely to develop anxiety and depressive symptoms during the COVID-19 outbreak compared to men. 36 This finding corresponds with extensive epidemiological studies which have found that women are, in general, at higher risk of developing depression. 45 "Metaworry", the persistent worry about one's own thoughts and cognitive processes, is more frequent in women than in men. Thus, it is possible that fear to COVID-19 triggers a negative metacognitive process in which one worries about one's own worrying which could potentially cause harm to oneself. 46 It is important to acknowledge that our study has several limitations. As in other studies performed during this period, we adopted the snowball sampling strategy, thus our population is biased and may not reflect the actual pattern of general population. In an ideal scenario we should conduct a prospective evaluation of the same group of participants a period after the pandemic. We acknowledge that additional longitudinal studies, such as cohort studies or nested case-control studies are essential in the future. However, we decided to compare anxiety and depression with an historic cohort, and although this control group is not exactly matched to our studied population, the prevalence of anxiety . CC-BY-NC-ND 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 May 15, 2020. . https://doi.org/10.1101/2020.05. 10.20095844 doi: medRxiv preprint and mood disorders are like those reported previously in Mexico. Other limitations include response bias due to fewer older subjects participating, the fact that sleep problems were not rigorously evaluated with a specific tool, and some states in our country were not represented in this work.

In conclusion, our study provides valuable information on the psychological impact . CC-BY-NC-ND 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 May 15, 2020. . CC-BY-NC-ND 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 May 15, 2020. pandemic compared to a historic control group. Anxiety or depression symptoms were considered if subjects had a score >8 in the HAD. Those subjects whose scores were between 8-10 were classified as "suspect", meanwhile those with a score > 11 were considered as a caseness.

. CC-BY-NC-ND 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 May 15, 2020. . https://doi.org/10.1101/2020.05. 10.20095844 doi: medRxiv preprint 

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The authors extend their sincere gratitude to Ms. Maria Medellin for her help for having translated and revised the grammar of this manuscript.

Jose María Remes-Troche https://orcid.org/0000-0001-8478-9659