Mental health status of Chinese residents during the COVID-19 epidemic

In late December 2019, the 2019 coronavirus disease (COVID-19) appeared in Wuhan City, Hubei Province, China [1]. On January 30, 2020, the World Health Organization (WHO) declared the COVID-19 epidemic as a public health emergency of international concern [2]. The number of confirmed cases and deaths is changing hourly and daily and can be tracked on the website of National Health Commission of China [3]. According to these numbers, the daily confirmed growth rate of cases and death growth rates reflect changes in the epidemic [4]. As of late February 2020, China had a total of nearly 80,000 confirmed cases and nearly 3000 deaths, thereby causing a large burden of morbidity and mortality.

As a result of the rapidly increasing numbers of confirmed cases and deaths, Chinese residents have been experiencing psychological problems, including anxiety and depression [5]. The severity of COVID-19 infection, the uncertainty of how to control the disease, and information overload, can raise concerns among the population [6]. In addition, with the implementation of isolation policy, social activities have been drastically decreased, and the psychological stress has increased [7], resulting in anger and loneliness [5]. The previous study has shown that such challenges and stresses may lead to common mental disorders [8]. Besides, cognitive factors may affect public mental health and influence anxiety and depression when facing the COVID-19 epidemic. The diathesis-stress theory states that the interaction between external life events and individuals’ internal lives leads to psychological problems [9]. The cognitive model of depression postulates that depression symptoms are maintained by negatively biased cognition, including negative attention bias, negative memory bias, and rumination [10‐12]. The negative cognitive processing influences what people attend to, how they interpret new information, and what they remember later in time, thus exacerbating and sustaining the negative mood that typifies depressive episodes [13, 14]. Research conducted over the last 50 years supports this proposition [15, 16]. In addition, negative cognitive processing bias could also negatively predict an individual’s mental health [17]. Therefore, this study assumed that the public’s mental health was related to external factors such as epidemic information, work environment, family conditions, and social activities, and internal factors such as cognitive processing.

Thus far, studies on depression and anxiety during COVID-19 have primarily focused on the medical staff. Only a few studies have examined the mental health of ordinary residents. Some previous studies have pointed out that the psychological impact caused by public health emergencies, such as the severe acute respiratory syndrome (SARS) epidemic in China in 2003 [18] and the Middle East respiratory syndrome (MERS) epidemic in 2012 [19, 20], may last for a long time and may bring severe psychological trauma to the people [21].

This cross-sectional study explores the effect of various factors on residents’ mental health under stress during public health emergencies. It provides accurate decision-making reference to the government departments with respect to the mental health of normal people.

Our web-based cross-sectional study identified a significantly high prevalence of anxious and depressive symptoms in Chinese residents during the COVID-19 outbreak. China Mental Health Survey (CMHS) conducted a cross-sectional epidemiological survey in 2019, which revealed that 3.6% of Chinese adults had depressive disorder symptoms, while 5.0% had anxiety [30]. The current study suggested that depression and anxiety symptoms rapidly increased when a major infectious disease occurred. Chinese residents showed a higher level of anxiety than depression; these factors were positively correlated. These findings were consistent with the previous study, which suggested that individuals with anxiety were prone to depression, and depressed people tend to be anxious [31]. Owing to the isolation policy, the social activities of the residents were markedly reduced. The lack of social activities led to a higher level of anxiety and depressive symptoms. Social activity is an essential way of sharing interest and socializing with familiar people. Frequent participation in social activities has been proven to be associated with decreased depressive symptoms [32].

The death growth rate and the confirmed growth rate of COVID-19 reflect the severity of the epidemic. During our survey, the volatility trends of death growth rate and confirmed growth rate were not identical. Strikingly, the confirmed growth rate had a greater effect on depression severity, and only the death growth rate could positively affect the anxiety levels. During the pandemic of COVID-19, people could seek information from official channels to stay informed about the situation. Due to the transmission of COVID-19 and the continuous adjustment of diagnosis and treatment programs, the fluctuation of epidemic data may cause fluctuations in the public’s psychological pressure.

Male respondents showed a significantly lower level of depressive and anxiety symptoms than their female counterparts. This phenomenon is consistent with previous research, which concluded that women are much more susceptible to stress and more likely to develop higher psychological distress during the COVID-19 outbreak than men [33]. This may be explained by the fact that women have the social role of the lead caregivers in their family and occupational environments, making them more sensitive to stress than their male counterparts; however, this premise needs to be further researched. Additionally, individuals between 56- and 65-years-old presented more severe depressive and anxiety symptoms than other age groups. Studies and reports showed a relatively low incidence risk of COVID-19 for young people but a very high mortality risk for elders [34, 35].

The results also showed that education level and occupation were related to depression. People with a high school diploma were prone to develop severe depressive and anxiety symptoms compared to others. The education level may be related to the acquisition and identification of epidemic information; yet, this needs to be further investigated.

During the outbreak, the medical staff had a higher level of depression and anxiety than individuals from other occupational sectors because they had to face a heavier workload and were at direct infection contact with patients infected with COVID-19. These pressures could be internalized, resulting in depression and anxiety [36]. Collective atmosphere and management style are critical factors that affect mood at work or school. Our results showed that occasional quarrels were more effective than peace, tranquility, and frequent quarrels in decreasing anxiety, while democratic management was the best approach for reducing anxiety and depression. An egalitarian and relatively free working atmosphere can increase people’s enthusiasm for work and help to cope with stress. In contrast, a bad work atmosphere is related to depression and anxiety in the working population [37]. Also, friendship is a protective factor for mental health when facing stress [38], which can decrease anxiety levels.

The family was another aspect that affects anxiety and depressive symptoms during the COVID-19 outbreak. Living with two parents led to lower depression than living with other groups. Having sisters or brothers and not being the only child in the family could decrease anxiety. The democratic parenting style and living with parents until the age of 10 years of age were also conducive to the epidemic’s response. Good family functionality was negatively correlated to stress and depressive symptoms [39]. Marital status also reflected the family situation. Compared to unmarried people, divorced people were more likely to be depressive. Intriguingly, job, and income were rapidly reduced while marital conflicts increased during the isolation period, which may be associated with the risk of depression [40].

Negative cognitive processing bias, especially negative attention bias and rumination, had a negative role in regulating people’s mental health. People with negative attention, tending to reports such as death and confirmed cases, could easily succumb to negative stimuli. Lacking attention flexibility that engages with positive information and disengages from salient negative information might cause the failure of adaptive emotion regulation processes [41]. The rumination refers to the repeated thinking and analysis of negative emotions and feelings, which affects the onset of depression [42]. Individuals with ruminant traits are likely to be immersed in depression and anxiety and cannot extricate themselves because of the overwhelming news reports that have already created a repressive emotional atmosphere. Negative memory bias means a tendency to recall over-general memory and more negative memory than normal subjects, which has been regarded as an important risk factor for the emotional disorder [43]. People with this bias might recall negative information about a similar situation during the SARS epidemic. Abstract memory lacks concrete detail and tends to classify coronavirus as a disaster, thus resulting in enhanced anxiety. Individuals with negative cognitive processing bias tend to pay more attention to negative information, continue to ruminate on negative emotions, and make negative explanations for events’ results, thereby affecting their mental health [17].

Since January 2020, the National Health Commission of China has published several guidelines for emergency psychological crisis intervention, established psychological assistance hotlines, and providing online mental health education for the COVID-19 epidemic [44, 45]. All these measures contributed to easing the public psychological disturbance and psychological harm. Based on the findings of the current study, we generated the following recommendations: (1) focus should be placed on the vulnerable groups, such as the elderly, women, medical staff, and high school educated people; the focus should also be placed on people’s family situation and social activity; (2) provide information on COVID-19 prevention, treatment, control for the public, avoid the release of false information, and the spread of rumors; (3) use cognitive training to reduce mental distress, focus more on individuals with high negative cognitive processing bias, encourage and teach them to use emotion regulation strategies, and separate attention from negative emotions when they feel anxious or depressive, in order to maintain and promote their mental health; (4) provide authoritative psychological evaluation procedures and online psychotherapy to prevent further mental health problems.

The present study has several limitations. First, this study used the method of cross-sectional design, this it is not possible to make causal inferences. Second, the study was limited to an online survey, which may lead to selection bias. We might overestimate the ratios of anxiety and depressive symptoms because people who voluntarily choose to participate in the survey might be more aware of their mental health issues than those who did not participate. Third, due to the web-based study design, we could not control the origin of the participants’ regions and guarantee the sample’s representativeness, which might affect the research results.

In this study, we assessed Chinese residents’ mental health status during the COVID-19 outbreak and identified the related risk factors for anxiety and depressive symptoms. The elderly, females, medical staff, and people with high school education were at higher risk of developing psychological issues. Negative cognitive processing bias had a negative role in regulating mental health. Psychological interventions should focus on vulnerable groups. Moreover, cognitive training that focuses on reducing negative cognitive processing bias might help alleviate the general public’s mental stress during the COVID-19 pandemic.