Background
Since December 2019, the COVID-19 pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the associated governmental restrictions have impacted daily life in most parts of the world. In France, the government introduced nationwide lockdown and home confinement on March 17, 2020 until May 11, 2020 [
1], which stipulated severe restrictions on social contacts, on many people’s ability to work, and greatly reduced access to services.
Recent cross-sectional studies have estimated the prevalence of anxiety and depression symptoms during the COVID-19 pandemic in different non-French populations, [
2‐
8] all finding high prevalence of generalized anxiety disorder (GAD) and depressive symptoms after the introduction of the pandemic. Since the COVID-19 outbreak, French adults seem to have an especially high prevalence of mental distress, including stress and anxiety, compared to other OECD countries [
9]. Especially people feeling lonely, women, young people, those with preschool aged children, having a low income, or living in cramped housing are identified as especially vulnerable in terms of mental health in the context of the COVID-19 pandemic [
4,
10‐
13]. A recent review has shown that quarantine during previous epidemics had a strong impact on mental health [
14], and studies conducted in the context of other infectious disease outbreaks have reported that symptoms of anxiety and depression were elevated during the time of the event and several months after [
15‐
17]. A deterioration in mental health outcomes is expected in the general population during a pandemic and lockdown period [
18], but little is known about the impact of these special circumstances on persons with mental health difficulties before lockdown. Yet individuals with preexisting mental health disorders may be one of the particularly vulnerable groups, when it comes to the effects of the lockdown on population mental health [
10,
12,
19,
20]. A systematic review investigating the COVID-19 pandemic and mental health, finds that patients with preexisting psychiatric disorders reported worsening in symptoms at the time of lockdown [
20].
As in other countries, lockdown in France was associated with an injunction on physical distancing, where it was prohibited to meet with people from other households [
1]. During the time of lockdown, loneliness had been considered as an important concern for mental health [
21], where loneliness was seen as the main risk factor for depression, anxiety and their comorbidity [
22]. Even in times without lockdown, loneliness and mental health difficulties are found to be highly associated [
10,
23,
24], while social isolation due to lockdown can be expected to have an impact on the risk of experiencing symptoms of depression and anxiety during lockdown [
4,
25].
With the knowledge we have about the mental health situation during lockdown, and groups that appear especially vulnerable, there is reason to believe that persons who experienced symptoms of anxiety/depression before the COVID-19 pandemic are more vulnerable to internalizing symptoms during lockdown than those with no such symptoms experienced earlier. In line with this, the aim of this study is to examine the association between preexisting symptoms of anxiety/depression and symptoms of anxiety/depression during the COVID-19 outbreak among a mid-aged French population. Furthermore, we are interested in examining other factors related to symptoms of anxiety/depression during the first lockdown in France, including sex, household income and loneliness.
Methods
Study population and procedure
This study includes 662 participants from the TEMPO COVID-19 project, a longitudinal follow-up study aiming to better understand French adults’ mental health situation during the pandemic. Data was collected seven times starting on the 24th of March 2020, 1 week after France declared lockdown. The TEMPO COVID-19 project is nested within the TEMPO (Trajectoires ÉpidéMiologiques en POpulation) cohort, which has been described in detail elsewhere [
26,
27]. Briefly the TEMPO cohort was set up in 2009 among young adults (22–35 years), who had previously taken part in a study on children’s psychological problems and access to mental health care in 1991 and 1999 [
28,
29]. In 2009, participants from 1991 were contacted to complete the TEMPO study, and were followed via self-completed questionnaires in 2011, 2015 and 2018 [
30]. From March to June 2020, TEMPO COVID-19 data were collected in seven periods of time. Invitations and reminders to participate were sent by email to all TEMPO participants with a valid email address, corresponding to a total of 1224 participants contacted at every time. Follow-up questionnaires were sent weekly for the first five data collections, and biweekly for data collections six and seven (for specific dates and number of participants see Supplementary Table
1).
Measures
Outcome: anxious/depressive symptoms during lockdown
Mental health during lockdown was measured using items from the
Anxious/Depressed syndrome scale based on the Adult Self Report (ASR)-Achenbach System. The ASR is a well-validated instrument to asses adult psychopathology and is used for both clinical and research purposes and includes in total 18 items [
31,
32]. Each item is rated on a three-point scale from 0 (
Not true), 1 (
Somewhat true or Sometimes) and 2 (
Very Often or Often True). To calculate scores of symptoms of anxiety and depression during lockdown, this study includes 8 items in the first follow-up questionnaire in 2020 and 13 items in the questionnaire used for the 2–7 follow up selected from the Anxious/Depressed syndrome scale [
33] (for specific questions selected see Supplementary Table
2). In the present study the Anxious/Depressed syndrome scale was dichotomized. To create a comparable anxiety/depression measure across points of follow-up the scores were transformed to a 0–100 scale. According to ASR guidelines, the 85th percentile serves to identify persons with clinically significant symptoms [
32]. The values on the 85th percentile for each data collection during COVID-19 were calculated, and the mean of these values resulted in a cut-off corresponding to a score of 34. This score was used to create a comparable dichotomous measure across the seven questionnaires during lockdown.
Preexisting symptoms of anxiety/depression
Information on participants’ past symptoms of anxiety and depression was included using the last available measure from prior waves 2018 (87%), 2011 (11%) or 2009 (2%) of the TEMPO cohort. In 2018 participants completed the same items from the ASR Anxious/Depressed syndrome scale as in TEMPO COVID-19 wave 1. For the subgroup that did not complete the 2018 TEMPO study questionnaire, mental health information was used from 2011, where participants reported information on major depression and generalized anxiety disorder subscales of the Mini-International Neuropsychiatric Interview (MINI) [
34,
35]. For the remaining subjects with no information on anxiety/depression symptoms from 2018 or 2011, information on anxiety/depression were included from 2009, where participants also answered items from the ASR. If no information were available from those 3 years, subjects were excluded from the analysis.
Covariates
Participants’ demographic, occupational, and economic characteristics were collected in the first questionnaire answered during lockdown. Marital status was grouped into ‘single, divorced or widowed’ vs. ‘married or in a civil union.’ Living situation was coded as ‘living with a partner with children,’ ‘living with a partner without children’ and ‘other,’ and housing situation as ‘living in a house’ vs. ‘living in an apartment.’ Participants’ educational attainment was dichotomized based on whether individuals had obtained up to an initial university degree (2 years post high school or less) or a bachelor’s degree or higher (at least 3 years post high school). Furthermore, we identified whether participants lived in an area with a high level of COVID-19 infections in March to June 2020, where ‘yes’ included the Paris region or Eastern France and ‘no’ included rest on France [
36]. Participants’ occupational status was defined by their employment type, which was divided into four groups; ‘stable’ defined as permanent contract, civil servant, or self-employed, ‘unstable’ defined as temporary contract or other short-term employment, ‘unemployed and looking for a job,’ and ‘unemployed and not looking for a job.’ Self-reported household income was dichotomized based on the best fitting category according to the median income in France (2500 euros or less per month vs. 2501 euros or more per month) [
37]. Preexisting financial difficulties were self-reported in 2018 and covering basic necessities (rent, heating or electricity costs, medical care or medication, and eating varied, sufficient and balanced meals). For individuals who did not respond in 2018, we used information on financial difficulties in the 12 months preceding lockdown. In each questionnaire, participants were asked the UCLA (University of California, Los Angeles) 3-item Loneliness Scale [
38], where the questions are rated from 1 (
Hardly never) to 3 (
Often). Individuals with a summed score from 3 to 5.9 were considered as “not being lonely,” and those with a score from 6 to 9 as “lonely” [
39].
Statistical analyses
To study the association between symptoms of anxiety/depression during lockdown and the previous measure of anxiety/depression, we started describing the TEMPO COVID-19 sample participants’ characteristics and their preexisting mental health situation. Second, we implemented bivariate and multivariate generalized estimation equation (GEE) models, with a logit link and binomial distribution as well as an unstructured correlation matrix, to examine the relationship between the outcome, that is, anxious/depressive symptoms during lockdown, and previous measure of anxiety/depression symptoms and covariates. To control for potential confounders, all covariates with a p-value < .20 in the bivariate GEE model was included. Factors adjusted for in the final model were: sex, living situation, occupational status, household income and measures of loneliness during lockdown. Lastly, interactions between previous measured symptoms of anxiety/depression and covariates were tested. Statistically significant interactions were included in the final model. All analyses were performed using SAS (version 9.4), and are based on a complete case analysis.
Results
In total, 729 individuals participated in at least one of the seven follow-up questionnaires during lockdown, 67 participants were excluded due to missing information, yielding a total sample of 662 subjects with complete data on at least one of the seven study questionnaires. In most cases (87% [
n = 575]) information on preexisting mental health difficulties was available in the 2018 TEMPO wave, and for subgroups in 2011 (11% [
n = 76]) and in 2009 (2% [
n = 11]). Descriptive statistics are presented in Table
1.
Table 1
Socio-demographic characteristics of TEMPO cohort study participants and mental health status prior to COVID-19-related lockdown (March–June 2020)
Sexa |
Male | 237 (35.8%) | 204 (41.2%) | 33 (19.8%) | < 0.0001 |
Female | 425 (64.2%) | 291 (58.8%) | 134 (80.2%) |
Agea |
Mean (SD) | 39.8 (3.65) | 39.9 (3.70) | 39.3 (3.47) | 0.3252 |
Marital statusa |
Married, or in a civil union | 528 (79.8%) | 401 (81.0%) | 127 (76.0%) | 0.1676 |
Single, divorced or widowed | 134 (20.8%) | 94 (19.0%) | 40 (24.0%) |
Living situationa |
Living with partner and children | 434 (65.6%) | 343 (69.3%) | 91 (54.5%) | 0.0016 |
Living with partner without children | 70 (10.6%) | 44 (8.9%) | 26 (15.6%) |
Other | 158 (23.9%) | 108 (21.8%) | 50 (29.9%) |
Housing situationa |
In a house | 450 (68.0%) | 343 (69.3%) | 107 (64.1%) | 0.2111 |
In an apartment | 212 (32.0%) | 152 (30.7%) | 60 (35.9%) |
Educational attainmenta |
Bac + 3 or higher | 471 (71.2%) | 355 (71.7%) | 116 (69.5%) | 0.5779 |
Bac + 2 or lower | 191 (28.8%) | 140 (28.3%) | 51 (30.5%) |
Living areaa |
Low level of COVID-19 incidence | 468 (70.7%) | 352 (71.1%) | 116 (69.5%) | 0.6854 |
High level of COVID-19 incidence | 194 (29.3%) | 143 (28.9%) | 51 (30.5%) |
Occupational statusa |
Stable contract type | 593 (89.6%) | 451 (91.1%) | 142 (85.0%) | 0.1235 |
Unstable contract type | 31 (4.7%) | 20 (4.1%) | 11 (6.6%) |
Not working, but looking for a job | 24 (3.6%) | 14 (2.8%) | 10 (6.0%) |
Not working, not looking for a job | 14 (2.1%) | 10 (2.0%) | 4 (2.4%) |
Household incomea |
2501 euros or more | 542 (81.9%) | 421 (85.1%) | 121 (72.5%) | 0.0003 |
2500 euros or less | 120 (18.1%) | 74 (14.9%) | 46 (27.5%) |
Financial difficultiesb |
No | 587 (88.7%) | 449 (90.7%) | 138 (82.6%) | 0.0044 |
Yes | 75 (11.3%) | 46 (9.3%) | 29 (17.4%) |
Lonelinessd |
No | 568 (85.8%) | 440 (88.9%) | 128 (76.6%) | < 0.0001 |
Yes | 94 (14.2%) | 55 (11.1%) | 39 (23.4%) |
Females represented 64% of study population. Participants were on average 40 years old, a majority were married, living with a partner and children, and working in stable work contract. Furthermore, most participants lived in a house and in a low COVID-19-incidence area (29% were living in the Paris region or Eastern France, where the incidence of COVID-19 was highest in March–June 2020).
Table
2 presents the results of bivariate GEE models, showing that preexisting symptoms of anxiety/depression were associated with significantly higher odds of symptoms of anxiety/depression during lockdown.
Table 2
Preexisting symptoms of anxiety/depression and covariates in relation to symptoms of anxiety/depression during COVID-19 related lockdown (March–June 2020). Bivariate GEE regression models (Unadjusted Odds Ratios (OR) and 95% Confidence Interval (CI), TEMPO cohort study, n = 662)
Preexisting symptoms of Anxiety/Depression at least once |
No | 1 | | |
Yes | 6.74 | [4.71–9.65] | < 0.0001 |
Sex |
Male | 1 | | |
Female | 2.59 | [1.71–3.93] | < 0.0001 |
Age | 0.97 | [0.93–1.02] | 0.1934 |
Living situation |
Living with partner and children | 1 | | |
Living with partner without children | 1.51 | [0.84–2.73] | 0.1683 |
Other | 1.45 | [0.84–2.73] | 0.0630 |
Housing situation |
In a house | 1 | | |
In an apartment | 0.84 | [0.57–1.22] | 0.3554 |
Educational attainment |
Bac + 3 or higher | 1 | | |
Bac + 2 or lower | 1.28 | [0.88–1.86] | 0.1979 |
Living area |
Low level of COVID-19 incidence | 1 | | |
High level of COVID-19 incidence | 0.78 | [0.54–1.17] | 0.2531 |
Occupational status |
Stable contract type | 1 | | |
Unstable contract type | 0.97 | [0.44–2.14] | 0.9475 |
Not working, but looking for a job | 3.56 | [1.74–7.29] | 0.0005 |
Not working, not looking for a job | 1.20 | [0.37–3.83] | 0.7635 |
Household income |
2501 euros or more | 1 | | |
2500 euros or less | 2.67 | [1.79–3.99] | < 0.0001 |
Loneliness |
No | 1 | | |
Yes | 2.45 | [1.91–3.13] | < 0.0001 |
Results of the multivariate adjusted model are shown in Table
3.
Table 3
Association between preexisting symptoms of anxiety/depression and symptoms of anxiety/depression during the COVID-19 related lockdown (March–June 2020). Multivariate GEE regression model (adjusted Odds-ratios (OR), 95% Confidence Interval (CI), TEMPO cohort study, n = 662)
Preexisting symptoms of Anxiety/Depression |
No | 1 | | |
Yes | 6.73 | [4.45–10.17] | < 0.0001 |
Sex |
Male | 1 | | |
Female | 2.07 | [1.32–3.25] | 0.0015 |
Living situation |
Living with partner and children | 1 | | |
Living with partner without children | 0.73 | [0.39–1.36] | 0.3208 |
Other | 0.48 | [0.22–1.06] | 0.0689 |
Occupational status |
Stable contract type | 1 | | |
Unstable contract type | 0.58 | [0.23–1.46] | 0.2441 |
Not working, but looking for a job | 1.92 | [0.89–4.16] | 0.0972 |
Not working, not looking for a job | 0.85 | [0.29–2.52] | 0.7714 |
Household income |
2501 euros or more | 1 | | |
2500 euros or less | 2.28 | [1.29–4.01] | 0.0044 |
Loneliness |
No | 1 | | |
Yes | 3.94 | [2.47–6.28] | < 0.0001 |
As hypothesized, a statistically significant association was found between preexisting symptoms of anxiety/depression and such symptoms during lockdown in March–May 2020 in the multivariate GEE analysis. Participants presenting symptoms of anxiety/depression prior to lockdown were about 7 times more likely to report symptoms of anxiety/depression during lockdown. Furthermore, being female, having a low household income and suffering from loneliness were associated with higher odds for symptoms of anxiety/depression during lockdown. A statistically significant interaction was identified between preexisting anxiety/depression and loneliness during lockdown (p = 0.04).
Conclusion
This study to examines the longitudinal effect of prior symptoms of anxiety/depression in the context of the COVID-19 pandemic and associated lockdown, and gives insight into the risk of anxiety/depression during lockdown among a mid-aged French population. The present study contributes to the identification of potential groups at risk for mental health consequences during the COVID-19 pandemic, including anxiety/depression symptoms prior to lockdown, females, people with low household income and lonely subjects. Furthermore, the study shows that loneliness is independently associated with symptoms of anxious/depression, when controlling for prior anxiety/depression symptoms. As proposed by Campion et al. and the World Health Organization [
19,
64], there is need for population-scale implementation of public mental health interventions, and our study suggests a focus on individuals with prior symptoms of anxiety/depression and those feeling lonely. In future research, it would be interesting to focus on the intra-individual changes in mental health before and during lockdown, and investigate related factors, as well as examine the mental health effects of the lockdown after the pandemic.
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