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      Psychological resilience, depression, anxiety, and somatization symptoms in response to COVID-19: A study of the general population in China at the peak of its epidemic

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          Abstract

          Rationale

          Psychological resilience is characterized as the ability to respond to extreme stress or trauma or adverse experience successfully. While the relation between public emergencies and psychological distress is well known, research on therelationship between psychological resilience and mental health is very limited during the outbreak of public health emergencies.

          Objective

          This research investigated the relationship between psychological resilience and mental health (depression, anxiety, somatization symptoms) among the general population in China.

          Method

          Psychological resilience, depression, anxiety, and somatization symptoms of 1,770 Chinese citizens were investigated during the epidemic peak of coronavirus disease 2019 (COVID-19) (23rd February 2020 to 2nd March 2020). The analyses were done through the Connor-Davidson Resilience Scale (CD-RISC), the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder-7 (GAD-7) scale, and the Patient Health Questionnaire-15 (PHQ-15) scale.

          Results

          The prevalence of depression, anxiety, somatization symptoms was found to be 47.1%, 31.9%, 45.9%, respectively, among all participants. From them, 18.2% showed moderate to severe symptoms of depression, 8.8% showed moderate to severe symptoms of anxiety, and 16.6% showed moderate to severe symptoms of somatization. Psychological resilience was negatively correlated with depression (standardized B = -0.490, P<0.001), anxiety (standardized B = -0.443, P<0.001), and somatization symptom scores (standardized B = -0.358, P<0.001), while controlling for confounding factors. Analysis of the three-factor resilience structure showed that strength and tenacity were correlated with depression (standardized B = -0.256, P<0.001; standardized B = -0.217, P<0.001), anxiety (standardized B = -0.268, P<0.001; standardized B = -0.147, P<0.001), and somatization symptoms (standardized B = -0.236, P<0.001, standardized B = -0.126, P<0.01).

          Conclusions

          Our results suggest that there is a high prevalence of psychological distresses among the general population at the peak of the COVID-19 epidemic in China, which is negatively correlated with resilience. Psychological resilience represents an essential target for psychological intervention in a public health emergency.

          Highlights

          • Investigated mental health and resilience in response to COVID-19.

          • The study took place at the peak of the COVID-19 epidemic in China.

          • In total, 18.2% had depression, 8.8% had anxiety, and 16.6% had somatic symptoms.

          • Resilience negatively correlated with depression, anxiety, and somatic symptoms.

          • Resilience represents an essential target for psychological interventions.

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          Most cited references28

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          Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed

          The 2019 novel coronavirus (2019-nCoV) pneumonia, believed to have originated in a wet market in Wuhan, Hubei province, China at the end of 2019, has gained intense attention nationwide and globally. To lower the risk of further disease transmission, the authority in Wuhan suspended public transport indefinitely from Jan 23, 2020; similar measures were adopted soon in many other cities in China. As of Jan 25, 2020, 30 Chinese provinces, municipalities, and autonomous regions covering over 1·3 billion people have initiated first-level responses to major public health emergencies. A range of measures has been urgently adopted,1, 2 such as early identification and isolation of suspected and diagnosed cases, contact tracing and monitoring, collection of clinical data and biological samples from patients, dissemination of regional and national diagnostic criteria and expert treatment consensus, establishment of isolation units and hospitals, and prompt provision of medical supplies and external expert teams to Hubei province. The emergence of the 2019-nCoV pneumonia has parallels with the 2003 outbreak of severe acute respiratory syndrome (SARS), which was caused by another coronavirus that killed 349 of 5327 patients with confirmed infection in China. 3 Although the diseases have different clinical presentations,1, 4 the infectious cause, epidemiological features, fast transmission pattern, and insufficient preparedness of health authorities to address the outbreaks are similar. So far, mental health care for the patients and health professionals directly affected by the 2019-nCoV epidemic has been under-addressed, although the National Health Commission of China released the notification of basic principles for emergency psychological crisis interventions for the 2019-nCoV pneumonia on Jan 26, 2020. 5 This notification contained a reference to mental health problems and interventions that occurred during the 2003 SARS outbreak, and mentioned that mental health care should be provided for patients with 2019-nCoV pneumonitis, close contacts, suspected cases who are isolated at home, patients in fever clinics, families and friends of affected people, health professionals caring for infected patients, and the public who are in need. To date, epidemiological data on the mental health problems and psychiatric morbidity of those suspected or diagnosed with the 2019-nCoV and their treating health professionals have not been available; therefore how best to respond to challenges during the outbreak is unknown. The observations of mental health consequences and measures taken during the 2003 SARS outbreak could help inform health authorities and the public to provide mental health interventions to those who are in need. Patients with confirmed or suspected 2019-nCoV may experience fear of the consequences of infection with a potentially fatal new virus, and those in quarantine might experience boredom, loneliness, and anger. Furthermore, symptoms of the infection, such as fever, hypoxia, and cough, as well as adverse effects of treatment, such as insomnia caused by corticosteroids, could lead to worsening anxiety and mental distress. 2019-nCoV has been repeatedly described as a killer virus, for example on WeChat, which has perpetuated the sense of danger and uncertainty among health workers and the public. In the early phase of the SARS outbreak, a range of psychiatric morbidities, including persistent depression, anxiety, panic attacks, psychomotor excitement, psychotic symptoms, delirium, and even suicidality, were reported.6, 7 Mandatory contact tracing and 14 days quarantine, which form part of the public health responses to the 2019-nCoV pneumonia outbreak, could increase patients' anxiety and guilt about the effects of contagion, quarantine, and stigma on their families and friends. Health professionals, especially those working in hospitals caring for people with confirmed or suspected 2019-nCoV pneumonia, are vulnerable to both high risk of infection and mental health problems. They may also experience fear of contagion and spreading the virus to their families, friends, or colleagues. Health workers in a Beijing hospital who were quarantined, worked in high-risk clinical settings such as SARS units, or had family or friends who were infected with SARS, had substantially more post-traumatic stress symptoms than those without these experiences. 8 Health professionals who worked in SARS units and hospitals during the SARS outbreak also reported depression, anxiety, fear, and frustration.6, 9 Despite the common mental health problems and disorders found among patients and health workers in such settings, most health professionals working in isolation units and hospitals do not receive any training in providing mental health care. Timely mental health care needs to be developed urgently. Some methods used in the SARS outbreak could be helpful for the response to the 2019-nCoV outbreak. First, multidisciplinary mental health teams established by health authorities at regional and national levels (including psychiatrists, psychiatric nurses, clinical psychologists, and other mental health workers) should deliver mental health support to patients and health workers. Specialised psychiatric treatments and appropriate mental health services and facilities should be provided for patients with comorbid mental disorders. Second, clear communication with regular and accurate updates about the 2019-nCoV outbreak should be provided to both health workers and patients in order to address their sense of uncertainty and fear. Treatment plans, progress reports, and health status updates should be given to both patients and their families. Third, secure services should be set up to provide psychological counselling using electronic devices and applications (such as smartphones and WeChat) for affected patients, as well as their families and members of the public. Using safe communication channels between patients and families, such as smartphone communication and WeChat, should be encouraged to decrease isolation. Fourth, suspected and diagnosed patients with 2019-nCoV pneumonia as well as health professionals working in hospitals caring for infected patients should receive regular clinical screening for depression, anxiety, and suicidality by mental health workers. Timely psychiatric treatments should be provided for those presenting with more severe mental health problems. For most patients and health workers, emotional and behavioural responses are part of an adaptive response to extraordinary stress, and psychotherapy techniques such as those based on the stress-adaptation model might be helpful.7, 10 If psychotropic medications are used, such as those prescribed by psychiatrists for severe psychiatric comorbidities, 6 basic pharmacological treatment principles of ensuring minimum harm should be followed to reduce harmful effects of any interactions with 2019-nCoV and its treatments. In any biological disaster, themes of fear, uncertainty, and stigmatisation are common and may act as barriers to appropriate medical and mental health interventions. Based on experience from past serious novel pneumonia outbreaks globally and the psychosocial impact of viral epidemics, the development and implementation of mental health assessment, support, treatment, and services are crucial and pressing goals for the health response to the 2019-nCoV outbreak. © 2020 VW Pics/Science Photo Library 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
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            Online mental health services in China during the COVID-19 outbreak

            At the start of 2020, the 2019 coronavirus disease (COVID-19), originating from Wuhan in Hubei province, started to spread throughout China. As a result of the rapidly increasing numbers of confirmed cases and deaths, both medical staff and the public have been experiencing psychological problems, including anxiety, depression, and stress.1, 2 Since January, 2020, the National Health Commission of China have published several guideline documents, starting with the notification of principles for emergency psychological crisis intervention for the COVID-19 epidemic on January 26, then the notice on establishing psychological assistance hotlines for the epidemic on February 2, and most recently, guidelines for psychological assistance hotlines during the COVID-19 epidemic on February 7. 3 During the severe acute respiratory syndrome epidemic in 2003, internet services and smartphones were not widely available. Therefore, few online mental health services were provided for those in need. 4 The popularisation of internet services and smartphones, and the emergence of fifth generation (5G) mobile networks, have enabled mental health professionals and health authorities to provide online mental health services during the COVID-19 outbreak. Fast transmission of the virus between people hinders traditional face-to-face psychological interventions. By contrast, provision of online mental health services is safe. To date, several types of online mental health services have been implemented widely for those in need during the outbreak in China. Firstly, as of Feb 8, 2020, 72 online mental health surveys associated with the COVID-19 outbreak could be searched for via the WeChat-based survey programme Questionnaire Star, which target different populations, including medical staff (23 of the surveys), patients with COVID-19 (one survey), students (18 surveys), the general population (nine surveys), and mixed populations (21 surveys); in Hubei province (five surveys), other provinces (15 surveys), all provinces, municipalities, and autonomous regions (36 surveys), and unspecified areas of China (16 surveys). One such multicentre survey involving 1563 medical staff, with our centre at Nanfang Hospital, Southern Medical University (Guangzhou, China) as one of the study sites, found the prevalence of depression (defined as a total score of ≥5 in the Patient Health Questionnaire-9) to be 50·7%, of anxiety (defined as a total score of ≥5 in the Generalized Anxiety Disorder-7) to be 44·7%, of insomnia to be 36·1% (defined as a total score of ≥8 in the Insomnia Severity Index), and of stress-related symptoms (defined as a total score of ≥9 in the Impact of Events Scale-Revised) to be 73·4%. These findings are important in enabling health authorities to allocate health resources and develop appropriate treatments for medical staff who have mental health problems. Secondly, online mental health education with communication programmes, such as WeChat, Weibo, and TikTok, has been widely used during the outbreak for medical staff and the public. In addition, several books on COVID-19 prevention, control, and mental health education have been swiftly published and free electronic copies have been provided for the public. As of February 8, 29 books associated with COVID-19 have been published, 11 (37·9%) of which are on mental health, including the “Guidelines for public psychological self-help and counselling of 2019-nCoV pneumonia”, published by the Chinese Association for Mental Health. Finally, online psychological counselling services (eg, WeChat-based resources) have been widely established by mental health professionals in medical institutions, universities, and academic societies throughout all 31 provinces, municipalities, and autonomous regions in mainland China, which provide free 24-h services on all days of the week. Online psychological self-help intervention systems, including online cognitive behavioural therapy for depression, anxiety, and insomnia (eg, on WeChat), have also been developed. In addition, several artificial intelligence (AI) programmes have been put in use as interventions for psychological crises during the epidemic. For example, individuals at risk of suicide can be recognised by the AI programme Tree Holes Rescue, 5 by monitoring and analysing messages posted on Weibo, and alerting designated volunteers to act accordingly. In general, online mental health services being used for the COVID-19 epidemic are facilitating the development of Chinese public emergency interventions, and eventually could improve the quality and effectiveness of emergency interventions.
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              Psychological interventions for people affected by the COVID-19 epidemic

              The coronavirus disease 2019 (COVID-19) epidemic has now spread across China for over a month. The National Health Commission has issued guidelines for emergency psychological crisis intervention for people affected by COVID-19. 1 Medical institutions and universities across China have opened online platforms to provide psychological counselling services for patients, their family members, and other people affected by the epidemic. However, Xiang and colleagues, 2 claim that the mental health needs of patients with confirmed COVID-19, patients with suspected infection, quarantined family members, and medical personnel have been poorly handled. The organisation and management models for psychological interventions in China must be improved. Several countries in the west (eg, the UK and USA) have established procedures for psychological crisis interventions to deal with public health emergencies. 3 Theoretical and practical research on psychological crisis interventions in China commenced relatively recently. In 2004, the Chinese Government issued guidelines on strengthening mental health initiatives, 4 and psychological crisis interventions have dealt with public health emergencies—eg, after the type A influenza outbreak and the Wenchuan earthquake—with good results.5, 6 During the severe acute respiratory syndrome (SARS) epidemic, several psychological counselling telephone helplines were opened for the public, and quickly became important mechanisms in addressing psychological issues. However, the organisation and management of psychological intervention activities have several problems. First, little attention is paid to the practical implementation of interventions. Overall planning is not adequate. When an outbreak occurs, no authoritative organisation exists to deploy and plan psychological intervention activities in different regions and subordinate departments. Hence, most medical departments start psychological interventional activities independently without communicating with each other, thereby wasting mental health resources, and failing patients in terms of a lack of a timely diagnosis, and poor follow-up for treatments and evaluations. Second, the cooperation between community health services and mental-health-care institutions in some provinces and cites in China has been decoupled. After the assessment of the mental health states of individuals affected by the epidemic, patients cannot be assigned according to the severity of their condition and difficulty of treatment to the appropriate department or professionals for timely and reasonable diagnosis and treatment. And after remission of the viral infection, patients cannot be transferred quickly from a hospital to a community health service institution to receive continuous psychological treatment. Finally, owing to a shortage of professionals, the establishment of psychological intervention teams in many areas is not feasible. Teams might consist of psychological counsellors, nurses, volunteers, or teachers majoring in psychology and other related fields, with no professional and experienced psychologists and psychiatrists. One individual often has multiple responsibilities, which can reduce the effectiveness of interventions. This situation can be resolved by improving relevant policies, strengthening personnel training, optimising organisational and management policies, and constantly reviewing experiences in practice. In the National Health Commission guidelines, 1 key points were formulated for different groups, including patients with confirmed and suspected infections, medical care and related personnel, those who had close contacts with patients (eg, family members, colleagues, friends), people who refused to seek medical treatment, susceptible groups (eg, older people, children, and pregnant women), and the general public. With disease progression, clinical symptoms become severe and psychological problems in infected patients will change; therefore, psychological intervention measures should be targeted and adapted as appropriate. Studies have confirmed that individuals who have experienced public health emergencies still have varying degrees of stress disorders, even after the event is over, or they have been cured and discharged from hospital, indicating these individuals should not be ignored.7, 8 Therefore, we should consider the disease course, severity of clinical symptoms, place of treatment (eg, isolated at home, ordinary isolation ward, intensive care unit), and other factors to classify individuals who need psychological intervention and to formulate specific measures to improve the effectiveness of these interventions. Under strict infection measures, non-essential personnel such as clinical psychiatrists, psychologists, and mental health social workers, are strongly discouraged from entering isolation wards for patients with COVID-19. Therefore, frontline health-care workers become the main personnel providing psychological interventions to patients in hospitals. For individuals with a suspected infection who are under quarantine or at home, community health service personnel should provide primary medical care and mental health care. However, because of complicated work procedures, heavy workloads, and a lack of standardised training in psychiatry or clinical psychology, community health service personnel do not always know how to mitigate the psychological distress of patients. A professional team comprising mental health personnel is a basic tenet in dealing with emotional distress and other mental disorders caused by epidemics and other public health emergencies. The national mental health working plan (2015–20) reported that 27 733 licensed psychiatrists (1·49 per 100 000 population), 57 591 psychiatric nurses, and more than 5 000 psychotherapists worked in China in 2015. 9 By the end of 2017, the number of licensed psychiatrists had increased to 33 400, and the number of psychotherapists, social workers, and psychological counsellors was also increasing year by year, 10 but their numbers were still too few to meet the needs of patients with mental disorders. Hence, training of mental health professionals at different levels is urgently required by the Chinese Government. Interventions should be based on a comprehensive assessment of risk factors leading to psychological issues, including poor mental health before a crisis, bereavement, injury to self or family members, life-threatening circumstances, panic, separation from family and low household income. 11 Any major epidemic outbreak will have negative effects on individuals and society. Lessons learned from terrorist events at the Pentagon and anthrax attacks in the USA showed the importance of pre-establishing community coalitions to mobilise resources efficiently and effectively and to respond successfully to the disaster-related mental health needs of affected individuals. 12 Planning of psychological interventions in China is usually done passively; few preventive measures are implemented before the occurrence of serious psychological issues caused by acute emergency events. The outbreak of COVID-19 has shown many problems with the provision of psychological intervention in China. Here we have suggested ways that the government could establish and improve the intervention system based on sound scientific advice, to effectively deal with the mental health problems caused by public health emergencies. © 2020 Pasieka 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
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                Author and article information

                Contributors
                Journal
                Soc Sci Med
                Soc Sci Med
                Social Science & Medicine (1982)
                Published by Elsevier Ltd.
                0277-9536
                1873-5347
                29 July 2020
                29 July 2020
                : 113261
                Affiliations
                [a ]Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing 401331, China
                [b ]Department of Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
                Author notes
                []Corresponding author: Name: Li Kuang Prof. Li Kuang , Institute: Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China. Department of Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, ChinaFull postal address: Department of Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing 400016, China. Tel: +86-023-89012696, Fax: +86-023-89012696 kuangli0308@ 123456163.com
                [1]

                Liuyi Ran and Wo Wang contributed equally to this work.

                Article
                S0277-9536(20)30480-9 113261
                10.1016/j.socscimed.2020.113261
                7388777
                32758794
                0e6dec43-4898-4a14-b846-39da423161fa
                © 2020 Published by Elsevier Ltd.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                : 15 July 2020
                : 26 July 2020
                Categories
                Article

                Health & Social care
                coronavirus disease 2019,psychological resilience,depression,anxiety,somatization symptoms,china,mental health,epidemic

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