key: cord-1041828-2sig28hb
authors: Ogawa, Takafumi; Shiratori, Yuki; Tachikawa, Hirokazu; Sodeyama, Noriko; Ota, Miho; Midorikawa, Haruhiko; Arai, Tetsuaki
title: Association between depressive state and behavioral changes induced by the state of emergency for Coronavirus disease 2019: Evidence from university students in Japan
date: 2021-11-10
journal: Acta Psychol (Amst)
DOI: 10.1016/j.actpsy.2021.103445
sha: 34fdf69db21dfd73855055f4df24f179a48f6f42
doc_id: 1041828
cord_uid: 2sig28hb

Coronavirus disease 2019 (Covid-19) has caused numerous problems worldwide since 2020. The pandemic and subsequent quarantine policies have resulted in numerous psychological problems among students. The quarantine policy forced students to change their behavior and refrain from going out. To date, the relationship between behavioral and psychological changes following the implementation of the quarantine policy has not been investigated. We conducted a web-based survey to investigate the change in time spent out of the house between before and after the implementation of the quarantine policy and how this related to changes in depression. We collected data from 12,088 students, which included the Patients Health Questionnaire-9, frequency of going out, and demographics. We divided subjects into three categories based on the frequency of going out before and after the policy was put in place. Results showed that students who frequently went out before the pandemic and strictly followed the government policy were significantly more depressed than those who did not frequently go out. In contrast, students who had always been reluctant to go out did not have a tendency for depression to worsen. Our findings indicate that behavioral modification leads to depression in those who previously had active social lives.

Coronavirus disease 2019 (Covid-19 1) ) has caused numerous problems worldwide since 2020. From the psychiatric perspective, the Covid-19 1) epidemic has not only induced anxiety and fear of infection but also depressive mood and loss of control in all populations. In Japan, the government implemented measures to quarantine all living residents to prevent the virus from spreading from April 7, 2020, to May 6, 2020. Such a significant policy had a drastic effect on lives, which has also impacted the mental health of many, especially young students.

Several studies have been conducted to examine the psychological state of students during periods of quarantine. In China, home confinement of adolescents has been shown to contribute to increased levels of anxiety and result in the disruption of education and socialization. In particular, the unprecedented lockdown policy during the Covid-19 1) pandemic has disrupted school schedules, which has resulted in disturbances of mental health in students (Sahu, 2020) . In Switzerland, students have reported feeling more emotionally detached from family members during the pandemic than they felt in previous years, which suggests that students experience significant psychological disturbances due to the prolonged periods of quarantine (Elmer, Mepham, & Stadtfeld, 2020) . Similarly, two cross-sectional cohort studies conducted in Switzerland found that J o u r n a l P r e -p r o o f more than a quarter of Swiss university students had symptoms of depression, the number of which was considerably higher than in the general population (Volken et al., 2021) . A repeated cross-sectional survey conducted in Poland demonstrated that depression significantly increased as the pandemic became more widespread (Debowska, Horeczy, Boduszek, & Dolinski, 2020) . Furthermore, a study conducted during the pandemic in Greece found that 12.4% of students suffered from depression and were more likely to have suicidal thoughts, which correlated with suicide risk (Kaparounaki et al., 2020) (Patsali et al., 2020) . Increases in anxiety and stress levels were also correlated with the implementation of a quarantine policy in Spanish university students (Odriozola-González, Planchuelo-Gómez, Irurtia, & de Luis-García, 2020). Being female, living alone, and low educational level were associated with anxiety during the Covid-19 pandemic (Sundarasen et al., 2020) . The reasons underlying students' anxiety are broad and include uncertainties regarding their future, Despite extensive research on the effect of the Covid-19 1) pandemic on mental health, there have not been any detailed investigations on the relationship between quarantine policy implementation and mental disturbance to date. One study that was conducted during the period of confinement due to the Covid-19 1) outbreak reported that people made habitual changes, such as increased sitting time (Romero-Blanco et al., 2020) . In general, unhealthy lifestyles are thought to be related to the development of mental disorders, such as anxiety and depression. For example, a study conducted in 2019 reported that unhealthy lifestyle habits and moderate to severe anxiety co-occur (Diaz-Godiño J et al., 2019) . Despite these numerous studies, whether changes in behavior following the implementations of the quarantine policy directly induced mental disorders has not been studied. Further research is needed to examine behavioral changes in those who originally stayed at home and those who actively went out following the implementation of the quarantine policy and how these changes were related to changes in mental state. Therefore, we decided to investigate how forced behavioral change induces depression and examine the extent of its effects and the modifying factors.

For the current study, we focused on hikikomori, which is a term first reported in Japan that refers to individuals who prefer to stay home. Hikikomori has J o u r n a l P r e -p r o o f Journal Pre-proof attracted global attention, and a proportion of these individuals are known to experience mental disorders. For hikikomori individuals, the quarantine policy would not have required a behavior change and thus, may not have exacerbated their depression.

Therefore, we also aimed to find out the effect of the quarantine policy on outing patterns and the mental state of hikikomori individuals.

All undergraduate and graduate students studying at the University of Tsukuba in 2020 were invited to participate in the study. Total number of students at the university was 17,198. We administered questionnaires to all students and 12,088 responses were returned (the rate of the responses was 70%). Of those who responded, 7,100 (58.7%) were male and 4,988 (41.3%) were female; were 2,977 (24.6%) were teenagers, 8,127 (67.2%) were in their twenties and 984 (8.2%) in their thirties or older.

The nationality of respondents was mostly Japanese and 58.7% were male. The age of the respondents ranged from 18 to over 70 years, and almost all respondents were aged < 30 years. The sociodemographic variables of the respondents are shown in Table 1. J o u r n a l P r e -p r o o f 2.2. Survey procedure

The survey was conducted using a cross-sectional design. It was administered to those who agreed to participate. Participants were asked to respond to our medical check-up examination. The examination contained the Patient Health Questionnaire 9 (PHQ-9 2) ) and a question regarding their frequency of outings. Analyses were performed on data collected between May 25, 2020, and June 22, 2020. Data were collected using an online survey platform, which was part of the university e-learning registration system.

The questionnaire included sociodemographic characteristics, which included sex, nationality, and age group, frequency of outings, and the PHQ-9 2) .

We used the questionnaire that the Japanese Cabinet administered in 2018 to investigate the quality of life of Japanese citizens. The survey asked, "How often do you go out?" and the possible responses were, "1. Going out every day for work or school"; "2.

Going out 3-4 times per week for work or school"; "3. Going out frequently for recreational activities and the like"; "4. Going out sometimes for social activities"; "5.

Journal Pre-proof Usually staying at home but going out for hobbies"; "6. Usually staying at home but going out to nearby convenience store"; "7. Come out of own room but do not leave home"; and "8. Do not come out of own room." We further divided these responses into three groups according to the frequency of outings: "Outing" (1-3), "Semi-homebound"

(4-6), and "Homebound" (7-8). The question was answered retrospectively, and the frequency of outings was assessed at two time points: before and after the quarantine order was implemented.

The PHQ-9 2) is an instrument used for measuring depressive symptoms and consists of nine items (Kroenke, Spitzer, & Williams, 2001) (Muramatsu et al., 2007) . Initially, this questionnaire was developed not only to assess depressive mood but also other mental disorders encountered in primary care. PHQ-9 2) can measure the severity of depression and each question is rated on a 4-point scale from 0 to 3 (thus the total score ranges from 0 to 27). The severity of depression according to the total score of the scale is defined as follows: minimal (1-4), mild (5-9), moderate (10-14), moderately severe (15) (16) (17) (18) (19) , and severe (20-27). The cut-off score of the PHQ-9 2) for detecting major depression is said to be 8-11, and the established cut-off value is 10 (Kroenke, 2012). In this study, we used this cut-off score to identify depression and created a binary Figure 1A shows the results of the group that went out frequently before the quarantine order was implemented. There was a significant difference in PHQ-9 2) scores between the groups that were classified according to frequency of outings after the quarantine order was put in place (p < 0.01). The multiple comparisons showed that the homebound group (mean = 4.5, standard deviation [SD 5) ] = 4.56) had significantly higher PHQ-9 2) scores than the outing (mean = 3.74, SD 5) = 3.89; p < 0.01) and semi-homebound groups (mean = 3.83, SD 5) = 4.02, p < 0.01). Figure 1B shows the results of the group that stayed home some of the time before the quarantine order was implemented. There were significant differences between the groups. However, the semi-homebound group had lower scores than the other two groups.

Finally, Figure1C shows the results of the group that were already confined to their home before the quarantine order was put in place. Although there were no significant differences between groups, the mean scores were highest in the outing group, followed by the semi-homebound group and then the homebound group.

Numerous studies to date have shown that various mental disorders have J o u r n a l P r e -p r o o f Journal Pre-proof arisen following the global epidemic of Covid-19 1) . However, the effect of students' behavioral changes because of the implementation of quarantine policies on the development of mental disorders has not been examined in detail. The purpose of this study is to examine this point.

Results showed that students who frequently went out before the quarantine order was implemented and withdrew after the order were significantly more depressed than the other student groups, whereas students who stayed at home before the restrictions were put in place and those who stayed at home during the restrictions showed no difference in depression. In other words, the group that experienced no changes in the frequency of outings tended to have lower depression scores than the group that experienced large changes in outings.

We considered that the behavioral changes resulting from the restrictions on going out because of the Covid-19 1) epidemic had a larger impact on the mental health of students who were previously socially active. However, when the students who had stayed at home before the implementation of the quarantine order were restricted from going out and continued to stay at home after the implementation, no change in their behavior occurred, which resulted in no change in their depression either. Therefore, we suggest that depression was induced by the forced behavioral change. To support this J o u r n a l P r e -p r o o f Journal Pre-proof notion, it has been reported that mice subjected to chronic mild stress (e.g., cage tilting and food deprivation) exhibit changes, such as enhanced immobility response during a forced swimming situation (Doe, 2013) . In addition, a chronic immobilization stress protocol has been proposed for the assessment of depressive behavior, whereby mice are placed in a small cage and subjected to chronic stress (H. Son, Yang, Kim, & Lee, 2019) .

Being forced to stay at home may also induce chronic stress, which may lead to a worsening of depression. A cross-sectional study conducted in Germany found that perceived stay-at-home orders are associated with higher depression and anxiety symptoms, whereas official stay-at-home orders are not associated with the exacerbation of such psychological conditions (Benke C, Autenrieth L, Asselmann E, & Pané-Farré C, 2020). Thus, the sense of being forced to make a behavioral change may be a more important factor that contributes to mental illness than the behavioral change itself.

Although our findings are crucial, the study has several limitations. Because the number of students who were originally withdrawn was small, we did not find a significant difference in PHQ-9 score in this group regardless of whether their behavior changed. Therefore, more data of this group is needed. Furthermore, the definition of hikikomori is both complex and controversial. One study offered innovative diagnostic J o u r n a l P r e -p r o o f Journal Pre-proof criteria for hikikomori, which included 1. marked social isolation in one's home; 2. duration of continuous isolation for at least 6 months; and 3. significant functional impairment or distress associated with their social isolation (Kato, Kanba, & Teo, 2019 )(Kato, Kanba, & Teo, 2020 . Our subjects may not be categorized as hikikomori according to these criteria. In addition, quarantine orders were not the same as those of other countries, and the extent of enforcement of policies differed between countries. It is also worth noting that hikikomori individuals spontaneously refrain from social activities, whereas Covid-19 1) -related isolation involved compulsory confinement (Kato, Sartorius, & Shinfuku, 2020) . Thus, the two conditions should not be considered equivalent. Additionally, this study was designed to be cross-sectional and retrospective, so the results need to be carefully evaluated.

Based on these findings, we encourage the development of innovative interventions to support students. A study conducted in the United States highlighted the urgent need for developing interventions and preventive strategies for mentally distressed students (C. . Our results also showed that the group that tended to be withdrawn had higher scores regardless of how much their frequency of going out changed. Furthermore, one study showed that loneliness is widespread among students, and such students need to be identified and J o u r n a l P r e -p r o o f contacted to prevent mental disturbances (Bruehlman-Senecal et al., 2020) . Our study suggested that we need to avoid compulsory interventions that force students to change the patterns of their behaviors. Moreover, it was also suggested that students who tend to be withdrawn as well as those who are frequently socially active should be closely monitored during periods of restrictions. Even before the current pandemic, identifying appropriate ways to approach patients and students who tend to be withdrawn has been challenging. The global pandemic may shed light on solutions to this problem by applying the lessons learned during this situation. For example, developing and employing digital healthcare tools may be useful. It is evident that further investigations are needed to provide effective support to those whose mental health has been affected under restrictive circumstances. 

The Patient Health Questionnaire

Psychological effects of the COVID-19 outbreak and lockdown among students and workers of a Spanish university

University students' changes in mental health status and determinants of behavior during the the covid-19 pandemic

Closure of Universities Due to Coronavirus Disease 2019 (COVID-19): Impact on Education and Mental Health of Students and Academic Staff

Effects of COVID-19 on college students' mental health in the United States: Interview survey study

A chronic immobilization stress protocol for inducing depression-like behavior in mice

Psychological impact of covid-19 and lockdown among university students in malaysia: Implications and policy recommendations. correlates of PTSD and depressive symptoms one month after the outbreak of the COVID-19 epidemic in a sample of home-quarantined Chinese university students

Depressive symptoms in swiss university students during the covid-19 pandemic and its correlates

Investigating mental health of US college students during the COVID-19 pandemic: Cross-sectional survey study

Figure 1 : Mean PHQ-9 scores of groups classified by their outing status before the quarantine order was

Horizontal axis indicates the frequency of outing after quarantine order. Vertical axis indicates average PHQ-9 score (PHQ-9 was measured once after the quarantine order was put in place). Error bars mean standard error and asterisks signify that

The authors declare no conflicts of interest. All authors report no financial relationships with commercial interests. We express our sincere thanks to Sarina