Generalized anxiety disorder and resilience during the COVID-19 pandemic: evidence from China during the early rapid outbreak

The 2019 coronavirus outbreak (COVID-19) was reported in late December 2019 in Wuhan, China, then spread to the majority of the world in just 2 months and was reclassified as a pandemic on March 11 by World Health Organization (WHO) [1‐3]. Official Chinese statistical records stated that by August 4, 2020, a total of 84,465 people had been infected, of which 4644 had died. By the same date, 17,918,582 people have been infected with COVID-19globally, and 686,703 COVID-19-related deaths were confirmed across 193 nations [4]. Several countries continue to observe a similar outbreak to that which was observed in China in February; at that time, the number of COVID-19 infected persons rapidly increased from 24,324 to 40,235 in just 7 days, and cases were recorded in every province of mainland China as well as across 24 countries [5]. China adopted tough measures, including quarantining Wuhan on January 23, enacting travel bans,closing highway, shutting down catering companies, and restricting group dinners [6]. In succession, all 31 provinces or autonomous councils have the highest public emergency responses up to January 29 [7]. Although strong policy and pressure are beneficial to controlling the spread of the virus, travel and work restrictions, as well as worry about the outbreak, could induce anxiety, depressive disorders, and post-traumatic stress disorder, which could pose a greater hazard to some individuals than COVID-19 itself [8].

Even under exposure to panic and potentially traumatic events, not everyone develops anxiety [9]. This heterogeneity in response to stress or stimuli was found to be partially owed to the protective psychological capacity of resilience, which can help people avoid psychopathology or maintain favorable mental status in the aftermath of trauma [10]. Resilience not only protects individuals from risk factors but also helps them recover or bounce back from an altered environment following an adversity [11]. The mechanisms of the promotion of mental health by resilience are recognized as facilitating intrapersonal competence (i.e., perceived competence, coping skills, and self-efficacy) and utilizing external resources appropriately (i.e., seeking friends or public agencies for help) [12]. Resilience buffers against the negative impacts of life stressors on common internalizing psychopathology such as generalized anxiety disorder (GAD) symptoms [13, 14]. During the coronavirus pandemic, GAD is unavoidable. About 41 and 23.1% of the general population of Cyprus reported symptoms associated with mild and moderate-to-severe GAD [15]. Among 1311 community-dwelling individuals in Bangladesh, 37.3% showed GAD symptoms, compared to an estimate 28% before the outbreak [16]. Risk factors for GAD problems have been described in prior research. Demographic factors predicting generalized anxiety include being female, being older (more than 30 years), having a higher education (above a bachelor’s degree), being married, and being a non-governmental employee [16]. Some behaviors like frequent social media exposure, and spending too much time thinking about the outbreak were positively associated with GAD in Chinese community adults [17, 18]. However, there has been little research on the ability of resilience, as a positive psychological factor, to protect mental health or compensate for adverse factors during a virus pandemic [19, 20]. Unlike the deficit model, resilience in positive psychology means more than simply the absence of mental disorder, but functions as a reserve or intrinsic capacity that can be drawn on as a buffer against a wide range of future adversities [21, 22]. Psychological intervention with resilience promotion is suitable for public mental health and proved effective to the general population during the COVID-19 pandemic [23]. In this study, we conducted a survey to assess anxiety among a Chinese population and examine the potential risks and protective effect of resilience for GAD in early rapid outbreak periods.

In this study, 22.6% of the sample experienced moderate to severe GAD during the early rapid outbreak in China. Hubei province, the first and worst outbreak area with over 10,000 COVID-19 patients, showed the highest GAD prevalence (35.4%). Participants who had traveled to Hubei within the past month also showed an increased GAD risk (AOR 1.90, 95%CI 1.42–2.54). This GAD prevalence during the outbreak period was much higher than that found by the latest report in a national sample, which indicated a 7.6% prevalence of anxiety disorders in China [24]. During the SARS [39], MERS [33], and Ebola [24] outbreaks, people were also more vulnerable to mental disorders caused by specific worry factors due to the high possibility of being infected by these viruses, the lack of appropriate prevention measures, and the strict biosecurity restrictions.

Determining the specific worry factors contributing to public anxiety may be beneficial to preventing mental disorders. This study found that worry about oneself or family members being infected with COVID-19 was associated with highest GAD prevalence, which is comparable to results from South Korea regarding fear of infection [33]. During the early stage of an outbreak, wearing a medical mask is one of the prevention measures recommended by WHO to limit the spread of certain respiratory diseases [40]; the initial shortage of these masks caused social panic [34]. Despite rationing of masks to each community to ensure hospitals’ demands were met, the hospitals still asked for social donations of protective supplies [34], which may cause higher GAD prevalence associated with obtaining masks in this study. While travel was restricted, people were still exposed to erroneous information on social media like prognosis of COVID-19 patients’ sequela or death and that drinking can prevent coronavirus infection, making it difficult for people to distinguish valid information [35], which may increase the GAD prevalence. Although COVID-19 vaccination opened to market for several weeks, the global inequities of vaccine distribution due to only a limited number of countries possess capacity to manufacture vaccines on their own against the virus [41].; thus, people may still be vulnerable to anxiety disorders due to concerns regarding the susceptibility and prognosis of COVID-19. Participants who were worried about delays in working and about decreased income were directly influenced by the uncertain work resumption time, for that stressful income situations can increase common mental health problems like anxiety, depression, etc. [42].

The most important finding of this study was the potential protective factors related to GAD. Resilience, the ability to maintain a state of normal equilibrium in the face of extremely unfavorable circumstances [11], has been demonstrated to have protective effects against mental disorders like depression [43], anxiety [44], and PTSD [45] after trauma exposure, which is consistent with the findings of this study. The capacity to tolerate high levels of fear and still perform efficiently within a military context has been demonstrated to be associated with high resilience [46], further explaining how high resilience is associated with low anxiety (fear of COVID-19). Additionally, we found that those with a college education or above had only about half the GAD prevalence of those with a lower education level. Considering the difficulties in distinguishing valid and truthful information, which is a source of public anxiety, more educated people can more easily find, distinguish, and accept correct information [47]. Furthermore, high educational attainment enhances one’s resilience level, which may indirectly compensate for mental disorders, especially after trauma [9, 48]. Ahmed performed a review and concluded that two underlying types of positive factors promote resilience: internal characteristics (self-esteem, trust, resourcefulness, secure attachments, sense of humor) and external factors (safety, religious affiliation, strong role models) [49]. Furthermore, this study identified a possible buffering function of resilience that can mediate the unfavorable effect of worry factors on GAD prevalence, which is consistent with previous research [50]. Moreover, the buffering effect of resilience on mental disorders caused by posttraumatic stress has been found to be stronger in individuals with more trauma experience [51]. Resilience is not a stable characteristic but a changeable one. For example, enhancing emotional regulation, cognitive flexibility and reappraisal, positive emotions, meaning-making, having purpose in life, and the ability to harness social support may help reinforce resilient functioning [52]. An asset-based approach through promoting resilience could be a novel approach to promoting public health—building upon the recognized strengths and developing the potential strengths of individuals, communities, and organizations rather than focusing on avoiding individual risk factors [53]. A study conducted at an Ottawa company using an asset mapping method identified 25 assets types that can enhance resilience levels in seven categories: (a) awareness, (b) human resources, (c) information and communication, (d) leadership and culture, (e) operational infrastructure, (f) physical resources, and (g) social capital [54]. An asset-based approach is suitable for addressing different characteristics of communities, regions, and even countries to help enact target policies.

There are some potential limitations to this study. First, causal inferences regarding the effects of worry factors and resilience on GAD prevalence cannot be made from this cross-sectional study. Second, due to the online survey process, selection bias, such as having fewer male respondents, may have affected the results. Lastly, this study did not collect data on mental disorder fluctuations that may characterize early rapid outbreak periods to some extent; the mental disorder prevalence could fluctuate over the course of the COVID-19 pandemic.

In conclusion, the findings of this study suggest that there is currently a high prevalence of GAD in China, especially in the first and worst outbreak area, Hubei province, and among those who traveled to Hubei in the month prior to data collection. Furthermore, all of the worries except worry about the prognosis of COVID-19 were found to be more prevalent in Hubei Province than in other outbreak areas. Worries about susceptibility to COVID-19 are positively and highly associated with GAD prevalence, and perceived barriers to preventing COVID-19 and perceived hazards of COVID-19 are also positively associated with GAD prevalence to some extent. A high level of resilience and higher education attainment are protective factors against GAD; resilience, in particular, may buffer against the development of mental disorders due to anxiety risk factors. It may be beneficial to decrease public anxiety prevalence through health education to enhance efficacy for accessibility of medical or mask supplies and objective understanding of infectiousness, harmfulness of novel coronavirus. The resilience promotion may be a critical and conducive program for COVID-19 mental health promotion.