This study highlighted how the first wave of the COVID-19 pandemic broadly impaired the mental well-being of the general Swiss population. Precisely, one-third (34%) of respondents reported impaired mental well-being. Variables associated with impaired mental well-being were being young, being at risk for a severe outcome, having one or more health problems, smoking, living in a single household, and stopping work due to disease control measures.
Our finding is coherent with another study conducted in Switzerland by de Quervain and colleagues focusing on stress. Their study collected data at two time points: the beginning of lockdown and during the partial lifting of lockdown measures. They focused on changes in stress levels and symptoms of depression. The comparative time point between the two studies is the beginning of lockdown. They found that about half of their sample (49.6%) had increased stress during confinement compared to stress levels before the COVID-19 pandemic. Respondents also reported a 57% increase in symptoms of depression, which were highly correlated with the changes in stress. The authors identified several reasons for the increased stress levels, such as changes at work, problems with childcare, or not being able to spend time with others [
40]. In our study, we also found a significant association with increased impaired mental well-being in those respondents who could not go to work because the workplace was closed as mandated by the government. Our results are also comparable with findings from the UK, Spain, and Italy during the first wave lockdown (between April 24th and May 1st). There, around 43% of the population was expected to be at risk of stress, anxiety, and depression [
41]. Perhaps because of the stricter lockdown measures imposed on those countries, the proportion of impaired mental health was higher. For example, Spain had hard confinement with internal travel restrictions, and with strict stay-at-home requirements. The population was allowed to leave home only to go to the grocery store, the doctor or the pharmacy. These restrictions were also valid for children. Meanwhile, in Switzerland stay at home was also expected but was not enforced and remained a recommendation from the authorities appealing to the citizens’ sense of personal responsibility. Likewise, it was recommended to self-isolate and self-quarantine as necessary. Additionally, closures of public spaces and restrictions to freedom of movement were the responsibility of the Cantons, and the Federal Government did not impose a general rule for the whole country [
4,
42‐
44]. We were further able to highlight the characteristics of those respondents who self-rated their mental well-being as impaired.
Demographic covariates of impaired mental well-being: age, residential environment and, household size
Older people had a smaller likelihood to report impaired mental well-being due to COVID-19 than younger people. In comparison, people aged between 18 and 29 had a doubling in the odds of reporting impaired mental well-being than respondents between 45 and 59 years old (OR = 1.99,
P = 0.001). This finding is consistent with the literature showing older age as a resilience factor for mental well-being [
40,
45‐
48] and younger age as a predictor for poor mental health and well-being [
49,
50]. According to Pro Juventute, a charitable foundation in Switzerland, its helpline has registered increasing demand from young people. Psychological consultations increased 40% between October and December 2020 compared to the same period last year. Their survey indicated that nearly 60% of 15–34-year-olds felt isolated and alone in society, more than any other age group [
51].
Regarding the type of residential environment, we found that urban living was associated with a 62% increase in the odds of reporting impaired mental well-being (OR = 1.62,
P = 0.008) compared to living in a rural environment. The environmental and social conditions of urban areas might challenge mental well-being. On the one hand, urban areas provide more opportunities for socializing, education, culture, work, and easier access to health care. On the other hand, urban-living includes easier access to drugs, exposure to crime and violence, poverty, pollution, traffic, loneliness, and a consequent higher need for stress processing [
52,
53]. To these life challenges occurring during everyday life, we have to add the restrictions imposed by the government during the lockdown and the higher risk of SARS-CoV-2 infection [
54].
We also found that respondents living with more people reported less impaired mental well-being than those living in single households. For example, respondents living in a household of two people had a 35% lower odds of reporting impaired mental well-being than those living alone (OR = 0.65,
P = 0.036). This protective effect of living with more people corresponds to other studies showing a potential association between living alone and low positive mental health (defined as comprising both hedonic and eudaimonic elements of mental wellbeing) as shown in a systematic review of studies published between 2014 and 2017 [
55]. During the pandemic, this might be especially important as people might fear spending the period of self-quarantine or self-isolation alone at home [
56].
Health covariates of impaired mental well-being: risk for severe COVID-19, smoking, and health problems
Our study showed that participants at risk of severe COVID-19 or sharing their household with someone at risk for severe COVID-19, had a 38% higher odds of reporting impaired mental well-being than participants not in this situation (OR = 1.38,
P = 0.05). These results correspond with literature showing chronic medical conditions as risk factors for anxiety and depression [
57,
58], and therefore impaired mental well-being.
Regarding smoking, our results are in line with other studies that show that smoking is associated with poor mental health [
49]. Smokers in our study were more likely to report impaired mental well-being than non-smokers (OR = 1.8,
P = 0.002). There is some contradictory evidence in the literature regarding the effect of smoking on COVID-19 infection severity. A preliminary meta-analysis suggested that active smoking was not significantly associated with the severe progression of COVID-19 [
59]. Nevertheless, increasing evidence indicates that smoking is more prevalent among severe cases of COVID-19 and probably also COVID-19 related deaths [
60]. In addition, risk factors for a severe COVID-19 outcome are often present in smokers, i.e., lung and cardiovascular disorders [
61].
We found that respondents with more health problems were more likely to report impaired mental well-being than their counterparts with no health problems (OR = 1.88,
P = 0.001). This was expected, as physical and mental health are both considered by the World Health Organization (WHO) as integral dimensions of health and well-being [
62], and they are dynamically related [
63,
64].
Access to mental health interventions and contact restrictions
Access to mental health care was diminished due to the COVID-19 pandemic disruption of services around the world. Factors that affect mental health services include, among others, risk of infection in long-stay institutions, barriers to meeting in-person or even reduction of available mental health professionals due to infection [
67]. Given the need to reduce personal interactions, online mental health services start to be widely accepted internationally [
12] and are well suited to providing access to health services without carrying any risk of infection [
68]. In Switzerland, psychiatric and psychological ambulatory care providers seem to have maintained the same level of service during the lockdown as before the pandemic, thanks to the government measures to finance teleconsultations [
69]. Remote sessions allowed service-provision while complying with the need for physical distancing. Simultaneously, there was an increase in demand for psychological support, especially from the younger citizens [
70], with some services reporting a 12% increase in calls compared to the previous year [
71]. Furthermore, we need to consider that depending on the evolution of the pandemic (i.e., duration and economic consequences), it is possible that still more people than usual will need psychosocial support, and this support would be most efficient when delivered through different channels. As reported by the Swiss Federal Office of Public Health, different generations, for example, tend to seek information and support in different ways: older residents tend to use the phone, the internet is mostly used by those in their middle age, and the younger tend to prefer mobile apps [
72], chat, email or SMS [
69].
Depending on how strict the governmental lockdown measures are, the promotion and support of mental health during a pandemic might become necessary. Strategies to cover pandemic-related mental health difficulties include the long-term maintenance of helplines for mental health support (in Switzerland currently financed by the Federal Office of Public Health) and the creation of new ones. New helplines could be advertised through several media (radio, TV, social media) to reach all population segments. Other strategies could involve increasing the support offered by psychiatric and psychotherapeutic care entities, especially as patients with previous mental illnesses are vulnerable to further impairment of their well-being during the pandemic. Besides, also mental health care could be further supported by general practitioners and pediatricians. Our findings suggest that public health initiatives providing social support and information about where to get help and remain connected (e.g., via helplines) should target particularly young people, people at risk for severe COVID-19, and those with an insecure financial situation as a result of the lockdown. As suggested by Gloster et al., [
73], interventions that promote psychological flexibility may alleviate the negative mental health consequences of the pandemic. Gloster et al., exemplify psychological flexibility as holding one’s thoughts lightly, be accepting of one’s experiences, engage in what is important to one despite challenging situations. On the economic level, those whose finances have worsened because of the pandemic measures should get quick and uncomplicated financial aid.
Limitations
The study was conducted in Switzerland and given cultural differences among countries, and the reactions of their governments to the pandemic, results might not be generalisable to populations other than the Swiss one. Within Switzerland, we also found differences among language regions. Residents from the Italian-speaking region reported significantly less impaired mental well-being than those from the German-speaking region. This result seems to reflect the cultural differences between regions in Switzerland, which we wanted to control for.
Also, the cross-sectional nature of the study has certain limitations. To be able to generalise results to the population the study sample has to be representative. For a population of about 8 million people and a survey sample of 1022 individuals, sampled at random per quotas from a very extensive panel, we estimated a margin of error of +/− 3.2% (for questions with two possible answers). Further, results were weighted based on age, sex, and language-speaking region data published by the Federal Office of Public Health, therefore ensuring that the sample was representative of the general population of Switzerland. Also, it is to be acknowledged that a cross-sectional design does not allow us to establish causal relationships, and thus our results show the strength of associations.
This study focused on self-reported impaired well-being during the lockdown during March and April 2020, using a simple question formulated to be understood by everyone. However, this question has not yet been validated. To validate this question it would be interesting to investigate objective measures of well-being, during the same period or even long-term, given that psychological effects after a pandemic tend to last long-term [
74,
75]. Nonetheless, we found a strong association between impaired mental well-being and the mental health concerns variables from validated instruments (namely feeling lonely, feeling worried or anxious, feeling down or depressed, or feeling less pleasure in doing things). This strong association (see
Supplementary materials) suggests that the question about “impaired mental well-being” measured what we intended. It might have worked as a general well-being concept which included the emotional components of the four mental health concerns.
We highlight here the possibility that our question “
Does the current COVID-19 situation impair your mental/emotional well-being? might feel leading to some readers. In hindsight, we think that it would have been appropriate to build this question in a more neutral way. For example, avoiding the word ‘impair’ directly in the question and perhaps rephrasing it as ‘influenced in any direction your mental well-being’. Consequently, we cannot completely exclude the possibility that our results might be biased given the structure of the question. Nevertheless, we do not think this is the case for the following reasons. (1) The COVID-19 pandemic, specially the first wave, had such an unprecedented and important impact in peoples’ lives, that we do not think anyone would be easily led by our question. On the one hand some people had their mental well-being challenged, while others felt a relieve from their daily habits. (2) The cross-tabulation between mental well-being and the screening questions (felt lonely, anxious, depressed, had less pleasure in doing things than before), shows significant differences in mental well-being between the group of participants who reported impaired mental well-being (who had significantly more symptoms) and the group reporting not-impaired mental well-being (less symptoms). This significant relationship between the variables is evidence that our main question was measuring mental well-being. It would have been suspicious if there were no significant differences between the groups. (3) Other studies, measuring different aspects of mental well-being found similar proportions of people affected [
40,
41]. If our question would have been leading, then we can imagine that our results would have been inflated and a much higher proportion of the population would have reported impaired mental well-being.
Also, it would have been interesting to study the link between local area deprivation and mental well-being status. Local area deprivation indices measure certain socioeconomic conditions, including social and material disadvantages [
76] in relatively small geographical areas [
77]. Deprivation indices are usually associated with health outcomes [
78] and therefore interesting to associate with measures of well-being. We could not calculate such an index with the current dataset, nor are we aware of such an index validated for Switzerland. Also, we did not control for other economic factors like respondent’s salary or household total income. Other studies in Switzerland have shown that there is an effect of economic deprivation in psychological well-being [
79], and others have found that participants with a lower socio-economic profile have a low participation rate in health surveys [
80]. Thus, we cannot exclude the possibility that our results are slightly biased and that the real impact of the first wave of COVID-19 pandemic was indeed even more challenging for the population.
It would have been interesting to ask those two-thirds of respondents who did not report impaired mental well-being, how they felt. Other studies have shown some people remained neutral, while for others the pandemic brought a situation to stress relief compared to their lives before the pandemic [
40]. Given the importance of resilience, it would have also been interesting to ask about factors that people consider useful to keep physically and mentally healthy while facing stressful life events.