Coping style, social support and psychological distress in the general Chinese population in the early stages of the COVID-19 epidemic

An outbreak of infections of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), initially called novel coronavirus (2019-nCoV), began on December 8, 2019, when several cases of pneumonia of unknown etiology were reported in Wuhan in Hubei Province of China [1]. In the early stages of this pneumonia, severe acute respiratory infection symptoms can occur, with some patients rapidly developing acute respiratory distress syndrome, acute respiratory failure, and other serious complications [2]. As of March 11, 2020, the total number of patients in China with confirmed coronavirus disease 2019 (COVID-19) was 80,955, of which 67,773 were in Hubei province, and the total number of COVID-19-associated deaths was 3162 [3] . At the end of January 2020, the World Health Organization declared the COVID-19 outbreak in China as a public health emergency of international concern.

Infectious diseases cause significant psychological distress, both in the general public and in health professionals [4]. The emergence of COVID-19 has parallels with the pandemic of human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS), the severe acute respiratory syndrome (SARS) outbreak and the threat of an avian influenza pandemic, all of which caused substantial concern among health authorities, the media, and the general public [5]. As a life-threatening disease, we can consider COVID-19 outbreak as a specific stress. Psychosocial responses towards infectious disease outbreaks are variable and can range in intensity, including feelings of anxiety, a sense of shame, failure or weakness of the individual and society; an underestimation of likelihood of survival; an overestimation of likelihood of infection [6]; an urge to take flight from the outbreak; excessive, inappropriate adoption of precautionary measures; and increased demand for healthcare services during a critical shortage [7]. Very few epidemiological data are available about mental health problems and psychiatric morbidity among those suspected or diagnosed with COVID-19, the health professionals treating them and the general population [8]. Therefore, the best strategies to respond to mental health challenges during the outbreak remain unknown.

Previous research has indicated that coping styles and social support are moderating variables in the relationship between stress and distress [9], and that the relationship among stress, coping strategy and support system is complicated [10, 11]. A framework has been constructed in the support/coping field, in which social support and coping strategy have main effects on stress without a significant interaction between them [12]. Coping strategies refer to the specific efforts, both behavioral and psychological, that people employ to master, tolerate, reduce, or minimize stressful events [13]. During exposure to stressors, different individuals, or the same individual under different conditions, can employ active or passive coping strategies [14]. Active coping strategies include (1) considering ways to overcome stress and make plans for subsequent efforts, (2) accepting the existence of stressful events, and (3) taking full advantage of the situation by learning lessons from it. Passive coping strategies include (1) refusing to acknowledge the existence of stressful events, (2) giving up on making efforts to pursue the goals set under stressful situations, and (3) strengthening stressful feelings. When confronted with a single stressor or constellation of stressors, individuals are forced to consider their coping resources and select a coping response accordingly. A previous study of post-traumatic symptoms in survivors after a catastrophic earthquake associated active coping with well-being, while passive coping was often related to psychological distress [15]. Nevertheless, another study found that passive coping styles may have beneficial effects on relieving stress and temporarily coping with setbacks, suggesting that the difference between the two coping styles may be quantitative [16]. This suggests the need to explore whether these coping styles increase or reduce psychological distress during the COVID-19 pandemic.

In addition to coping strategies, effective social support has consistently been reported to protect individuals from developing mental health problems when they experience stressors [17]. Social support can be defined as a series of support measures accessible to an individual through their social relationships with other individuals, groups, and the larger community, and can be divided into three components: subjective support, objective support, and the utilization of support [18]. There are two possible mechanisms through which social support can influence mental and physical health. One is through main effects: social support is salutary for all individuals independent of the extent of stress that they are currently facing. The other mechanism is a stress-buffering model, in which the social support of others may have an ameliorating effect on life stressors, particularly for individuals under greater stress [19]. The beneficial effects of social support on psychological well-being have been widely studied and well documented across the general population and patients with various illnesses [18, 20]. The role of social support is generally beneficial and most findings demonstrate this protective role [21]. However, social support is not always beneficial, as a study found that while Asians are more likely to benefit from implicit social support (social networking), Caucasians are more likely to benefit from explicit social support (event-specific advice) [22]. The potentially complex effect of social support on psychological distress during the COVID-19 outbreak needs to be explored.

The severity of the psychological burden that COVID-19 places on the general population was not clear at the onset of the outbreak, and a model to guide successful interventions was lacking. Little is known about how Chinese are coping with the COVID-19 stressor. Based on previous studies, we aimed to investigate the psychological status of the general population in the early stages of the COVID-19 outbreak and explored factors influencing psychological distress. We further compared psychological distress, their coping style/social support and other demographic factors between the participants who did or did not suspect that they were infected. We hypothesized that an active coping style and social support were protective factors against psychological distress in the general Chinese population in the early stages of the COVID-19 epidemic. We further hypothesized that population with suspected infection would show higher psychological distress, use less active coping styles or more passive coping styles and have less social support than those without suspected infection. Our results may help provide the basis for psychological intervention programs.

To the best of our knowledge, this appears to be the first study to examine psychological distress in the general population in mainland China during the COVID-19 outbreak, and to investigate factors associated with that distress. The results of the present study show that in February 2020, when there were significant public concerns about the new coronavirus pandemic outbreak, 22.8% of our participants reported high levels of psychological distress (K6 score ≥ 13). Respondents with suspected infection reported higher levels of psychological distress than those without suspected infection, and the two groups differed in several sociodemographic variables, coping styles and support systems. Among those without suspected infection, factors significantly associated with high psychological distress were unmarried status, spending > 6 h per day searching for information about COVID-19, a passive coping style and lower social support.

The present study was conducted during the first two weeks of the COVID-19 outbreak, since human-to-human transmission was announced on January 20, 2020 [29]. In our study, 22.8% of participants had high psychological distress based on the cut-off score of 13 [30]. The prevalence of high psychological distress in our samples is lower than the 39.3% in a retrospective survey of perceived psychological distress in the construction industry, schools, businesses and residents in urban and rural areas during the SARS outbreak [31]. Our results may be more reliable than a retrospective study because our data were collected and analyzed during the stressor event. At the same time, the prevalence rate in our study is higher than the 17.3% of health care workers in Taiwan who showed significant mental symptoms during the SARS epidemic [32]. These findings suggest that the COVID-19 outbreak places a substantial burden on the mental health of the general population in China. Therefore, urgent measures are needed to enhance mental health services during the COVID-19 crisis.

In our study, nearly all the respondents with suspected infection showed high psychological distress, indicating high probability of having a severe mental illness and that specific intervention is needed for this subgroup [33]. This subgroup, compared to respondents without suspected infection, used less active coping styles and more passive coping styles during the outbreak; they had lower objective social support, subjective social support and utilization of social support; they were younger, had less education and lower family income; and they were more likely to be residents in Hubei Province, to have had contact with the epidemiological area (Wuhan), and to live in communities where COVID-19 cases were present. There are several explanations for the high psychological distress. It may be due to the fear of being infectious, being placed in quarantine, or suffering financial loss, stigma or discrimination. It may be due to a sense of guilt, frustration, boredom, or a feeling of having inadequate supplies or information. All these factors are stressors during the COVID-19 pandemic [34, 35]. Another potential explanation is belonging to a low-income social class, being younger, and having less education and low-skilled employment, which are risk factors for distress related to COVID-19. Indeed, being younger, being less attached to school education and belonging to a lower-income community are risk factors for distress during exposure to acute and chronic stressors in US immigrants [32, 36]. These factors may also impact social support and coping strategies: low-income, less-educated young adults are reported to lack social support and be more prone to adopting passive coping strategies, which are major risk factors for depressive symptoms in university students [37]. Finally, it is not surprising that those suspected with infection had more closely contact with Wuhan city, since COVID-19 was first observed in Wuhan. News coverage of the COVID-19 outbreak in Wuhan initially focused on the high infectivity and fatality, potentially creating fear and panic. In addition, in order to decrease the risk of disease transmission, Wuhan authorities suspended public transport indefinitely from January 23, 2020. A range of measurements were urgently adopted, 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 dispatching of external expert teams to Hubei Province [38]. The process of SARS-CoV-2 infection control and prevention involves the use of personal protective equipment, quarantine, and isolation, all of which may be further associated with fear and anxiety. It is reasonable to conclude that under these circumstances, the general population is under substantial stress and may need special care and psychological intervention.

For respondents without suspected infection, an active coping style and social support were protective factors against psychological distress in our regression model. On the other hand, unmarried status, spending more than 6 h per day searching for information about the COVID-19 outbreak, and passive coping styles were risk factors of high psychological distress.

We found that unmarried respondents were two times more likely to have increasing psychological distress in our logistic regression models. Our results are consistent with a recently published analysis in China showing that marriage was a determinant of psychological distress in the general population, and that unmarried individuals showed higher psychological distress during the COVID-19 outbreak [39]. Social support from partners and family members has been associated with well-being [40], and existing literature reveals considerable differences in social support among married, formerly married, and never-married people: unmarried people are less likely than married people to report having close family members or friends [41]. In addition, married people have larger help networks than unmarried or divorced individuals [42]. Unmarried subjects often do not benefit from the support of a spouse or family [43, 44].

Respondents without infection who showed high psychological distress (K6 score ≥ 13) also showed a higher frequency of passive coping style, such as problem-avoidance, fantasy, and self-blame. Our results are highly consistent with the findings in the subgroup of participants with suspected infection, in whom passive coping strategies were also associated with high psychological distress. Our results are also consistent with a previous meta-analysis that reported a strong association between passive coping style and depression [45]. Previous research indicated that coping styles can affect how a stressful event is perceived and how it is managed [10]. Since coping can involve “all efforts to manage taxing demands, without regard to their efficacy or inherent value” [10], it is not necessarily associated with a good outcome. Our findings are consistent with other studies that associate higher stress with greater use of emotion-oriented and social diversion-oriented coping [46].

The COVID-19 outbreak in China is substantially affecting the mental health of the general population. Mental health interventions should be implemented in a timely manner for individuals with suspected infection. Our results showed that positive coping strategies and increased social support significantly correlated with lower psychological distress. This suggests that the general population, especially those directly affected by the pandemic, should be taught active coping strategies and be encouraged to seek and maintain social support [52]. We believe that efficient mental healthcare in the national public health emergency system will empower China and the world during the campaign to contain and eradicate COVID-19 [53].