Psychomorbidity, Resilience, and Exacerbating and Protective Factors During the SARS-CoV-2 Pandemic
A systematic literature review and results from the German COSMO-PANEL
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Background: The SARS-CoV-2 pandemic has caused mental stress in a number of ways: overstrain of the health care system, lockdown of the economy, restricted opportunities for interpersonal contact and excursions outside the home and workplace, and quarantine measures where necessary. In this article, we provide an overview of psychological distress in the current pandemic, identifying protective factors and risk factors.
Methods: The PubMed, PsycINFO, and Web of Science databases were systematically searched for relevant publications (1 January 2019 – 16 April 2020). This study was registered in OSF Registries (osf.io/34j8g). Data on mental stress and resilience in Germany were obtained from three surveys carried out on more than 1000 participants each in the framework of the COSMO study (24 March, 31 March, and 21 April 2020).
Results: 18 studies from China and India, with a total of 79 664 participants, revealed increased stress in the general population, with manifestations of depression and anxiety, post-traumatic stress, and sleep disturbances. Stress was more marked among persons working in the health care sector. Risk factors for stress included patient contact, female sex, impaired health status, worry about family members and significant others, and poor sleep quality. Protective factors included being informed about the increasing number of persons who have recovered from COVID, social support, and a lower perceived infectious risk. The COSMO study, though based on an insufficiently representative population sample because of a low questionnaire return rate (<20%), revealed increased rates of despondency, loneliness, and hopelessness in the German population as compared to norm data, with no change in estimated resilience.
Conclusion: Stress factors associated with the current pandemic probably increase stress by causing anxiety and depression. Once the protective factors and risk factors have been identified, these can be used to develop psychosocial interventions. The informativeness of the results reported here is limited by the wide variety of instruments used to acquire data and by the insufficiently representative nature of the population samples.
The SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pandemic has led to over 11.5 million confirmed cases and more than 540 000 deaths worldwide since the end of 2019/beginning of 2020) (as of 10.07.2020) (1, 2). A pandemic on this scale causes stress and mental health burdens in the population (3, 4). These include:
- The fear that one/others might fall ill or die due to the virus
- Psychological distress as a result of:
– Isolation or quarantine measures
– Financial difficulties (for example, due to job loss)
– Responses to the pandemic on a state level (for example, school closures) (5).
The aim of this article is to provide an overview of studies from China and other countries on stress and mental burden in the general population as well as in healthcare workers. The results of three cross-sectional surveys conducted in the German population on psychological distress and resilience are also presented. By describing identified risk and protective factors, it is our intention to inform scientists and decision-makers in the healthcare system as to where psychosocial interventions to cope with the pandemic could be deployed.
Systematic literature analysis
The approach to the systematic literature analysis is described in detail in the eMethods and eBox. Parallel to this, a protocol was developed according to PRISMA guidelines (7) and registered in OSF Registries (osf.io/34j8g). The present analysis included studies that met the criteria listed in Table 1. A systematic literature search was conducted in the electronic databases PubMed, PsycINFO, and Web of Science (Core Collection) for publications in the period 01.01.2019 to 16.04.2020. Study selection and data extraction of included studies, as well as quality assessments using a modified version of the NIH-NHLBI instrument for cross-sectional studies and cohort studies (8), were carried out by two pairs of independent reviewers (NR, MB and NR, JSW). Any disagreement was resolved through discussion or by involving a third assessor (KL) at each stage of the literature analysis. There was high inter-rater reliability (κ1 = 0.875; κ2 = 1) on the title/abstract and full-text screening levels. The data extracted for each study included are presented in the eMethods. For five areas of psychological distress (anxiety and worry, depression, posttraumatic stress, sleep disorders, stress), the respective proportion of a sample showing elevated values (>cut-off) on an appropriate scale was extracted, if indicated. Comparisons with norm data were also taken into consideration for the data extraction. Due to the heterogeneity of the studies included, no quantitative synthesis of study results was carried out.
Data collection on psychomorbidity and resilience in Germany
- 24./25.03.2020, wave 4
- 31.03./01.04.2020, wave 5
- 21./22.04.2020, wave 8.
The quotas match the German population in terms of age, sex (crossed), and German federal state (uncrossed). Due to the response rates of 19% (wave 4), 14% (wave 5), and 15% (wave 8), the results are representative of the German population to only a limited extent. Psychological distress was assessed on the basis of five items for the period of the previous 7 days:
- “I felt nervous, anxious, or on edge” (item 1, GAD-7, )
- “I felt depressed” (item 6, ADS )
- “I felt lonely” (item 14, ADS )
- “I felt hopeful about the future” (item 8, ADS )
- “Thoughts about my experiences during the Coronavirus pandemic caused me to have physical reactions, such as sweating, trouble breathing, nausea or a pounding heart” (item 19, IES-R ).
To estimate the reported overall psychological burden, the mean value of the five items was determined. Suicidal tendency was not assessed. In order to estimate fear of SARS-CoV-2, the mean value of nine items tailored to the situation were recorded. The subjective assessment of resilience was surveyed with the Brief Resilience Scale (BRS [14, 15]). The results of the COSMO study were compared with the norm data of the Generalized Anxiety Disorder Screener (GAD-7) (11), the German General Depression Scale (Allgemeine Depressionsskala, ADS) (12), and the Brief Resilience Scale (BRS) (14, 15) for the German population before the outbreak of the SARS-CoV-2 pandemic.
Systematic literature analysis
The literature search initially identified 1173 studies, of which n = 18 studies with i = 18 reported samples were included in the analysis according to the inclusion criteria (eFigure).
Table 2, eTable 1, and eTable 2 provide an overview of the included studies, their study populations, as well as the survey instruments and cut-off values used.
In total, the following publications with 79 664 participants were taken into consideration:
- 16 nonrepresentative studies from China on psychological burden (data on diagnoses were not available) published between 06.03.2020 (first study: ) and 15.04.2020 (e1)
- One study from India
- A multinational study from China, Hong Kong, Taiwan, and Macao.
No European studies were available at the time of the literature search. Sample sizes ranged from 180 (e2, e3) to 52 730 (e4) participants (Table 2). It was not possible to calculate average age or sex distribution due to lacking data in some studies (eTable 1). The quality assessment rated nine of the 18 studies as poor, six as fair, and three as good (eTable 3).
Of the seven general population-based studies and the five conducted in mixed-population groups, seven studies (n = 16 113) reported data on the point prevalence of anxiety symptoms (1–82% of respondents), while five studies (n = 8308) recorded the prevalence of depressive symptoms (3–20%). Three studies (n = 1758) reported data on the presence of posttraumatic stress symptoms among study participants as percentages (7–54%), while three studies (n = 6903) reported on sleep disorders (13–31% of participants). One study (n = 1210) reported increased symptoms of stress in 8% of respondents. None of the studies recorded suicidal tendency. Prevalence figures were determined using the reported cut-off value for each study and instrument (eTable 2).
Only two studies performed comparisons of the frequency of psychopathological symptoms with norm values in the general Chinese population before the outbreak of the SARS-CoV-2 pandemic (i.e., prior to 20.01.2020, since this is the date on which human-to-human transmission became known [e5]) and in the absence of effects from other epidemic events. One of these studies showed increased levels of anxiety (an approximately seven-fold higher prevalence: 35.1 versus 5% [e6]) and increased levels of depression (a more than five-fold higher prevalence: 20.3 versus 3.6% [e6]), while another study showed increased posttraumatic stress symptoms (an almost two-fold higher prevalence: 7% versus 3.7% [e7]).
Of the six studies that investigated only healthcare workers and the five that studied the subgroup of healthcare workers as well as mixed population groups, seven studies (n = 8234) reported on the point prevalence of anxiety symptoms (13–70% of healthcare workers) and five studies (n = 7470) on the prevalence of depressive symptoms (12–50%). Three studies (n = 2481) reported data on the presence of posttraumatic stress symptoms among study participants as percentages (27–72 %), while four studies (n = 5428) reported on sleep disorders (24–38% of participants). One study (n = 927) reported symptoms of stress in 22% of respondents. Prevalence figures were determined using the reported cut-off value for each study and instrument (eTable 2).
Only two studies compared the frequency of psychopathological symptoms (anxiety and sleep disorders, respectively) with norm values in the general population (comparisons with healthcare workers before the current SARS-CoV-2 pandemic were not available). One study revealed statistically but not clinically relevant levels of anxiety (mean value of the Self-Rating Anxiety Scale (SAS, scale span not given) 32.19 ± 7.56 versus 29.78 ± 0.46; t = 4.27; p <0.001 [e2]), while the other showed only a slight increase in sleep-related symptoms (mean value in the Pittsburgh Sleep Quality Index (PSQI, scale span 0–21) 8.583 ± 4.567 versus 7 (standard deviation not reported, [e3]).
Table 3 and eTable 4 provide a summary of the protective factors and risk factors for psychomorbidity due to the COVID-19 pandemic from the 19 studies. Most studies identified the following parameters as risk factors:
- Contact with SARS-CoV-2 patients (n = 5 studies)
- Female sex (n = 5)
- Healthcare professions (n = 4)
- Low (perceived) health status (n = 3)
- Concern for loved ones (n = 2)
- Poor sleep quality (n = 2).
In contrast to this, one study (e8) found an increased risk in healthcare workers not in contact with SARS-CoV-2 patients and another (e9) an increased risk in men. Professional qualification also had varying effects in the different studies (6, e2, e9). Protective factors were identified in 10 studies, with a broad spectrum of factors emerging.
Exploratory analyses of psychomorbidity and resilience in Germany
At the three measurement points (wave 4, 5, and 8) in the COSMO study (9, 10), 1114, 1030, and 1012 different individuals in the German population were anonymously surveyed, respectively. Since the samples did not differ significantly with regard to sex and level of education and only slightly with regard to age (F [2, 3153] = 22.38, p = <0.001, η² = 0.014), one can compare the samples with one another (eTable 5). In a comparison of the ADS and the GAD-7 items (11, 12) with the values for the German population before the pandemic, the COSMO sample shows small effects for increased psychological distress (d = 0.15 to d = 0.28) (Table 4). The mean subjective assessment among respondents of their resilience (the ability to recover from stressful events) remains unchanged compared to a German norm sample (14) (p = 0.073, d = 0.05, Table 4).
The reported psychological burden due to depressive symptoms (ADS) remained at a slightly increased level consistently over the three waves of the survey, whereas anxiety due to SARS-CoV-2, physical symptoms when thinking about the SARS-CoV-2 pandemic, and overall psychological distress declined over time (Table 4). No differences were seen over time in the subjective assessment of resilience. Men assessed their resilience higher than did women (p <0.001, d = 026). Older individuals assessed their resilience higher (r = 0.169, [95% confidence interval: 0.152; 0.186], p = <0.001) and their psychological burden lower than did younger individuals (r = –0.228, [−0.245; −0.211], p = <0.001). Fear of SARS-CoV-2 was independent of age (r = 0.013; [0.005; 0.031], p = 0.482) (eTable 6).
Also when checking for self-assessed resilience as a possible confounding variable, evidence of various risk factors for psychomorbidity were seen (young age, female sex, own children, single parenthood, migrant background, living alone, or more than two people in a household). Practicing a healthcare profession was not identified as a risk factor (eTable 6).
The systematic literature analysis of the primarily Chinese studies provides evidence of an increase in anxious, depressive, and posttraumatic stress symptoms. More pronounced symptoms of depression, anxiety, and sleep disorders can be seen in healthcare workers (Table 3). In accordance with this, the results of the COSMO study suggest that the investigated samples show slightly higher levels of psychological distress (anxiety, depression, hopelessness) compared to the general German population prior to the outbreak of the SARS-CoV-2 pandemic. At the same time, one sees that symptoms of anxiety abate again over time, consistent with a functional psychological adjustment to a stressful event (3, 17, 18, 19). The absence of change in self-assessed resilience as recorded using the BRS (14) compared to before and during the SARS-CoV-2 pandemic can possibly be explained by the fact that the time period from onset of the stressor (the pandemic) was too short for self-assessed resilience to be revised. The age effects reported in the validation studies (14, 15), according to which younger people report a higher subjective ability to recover from stressful events, are in complete contrast to the results of our study, while the gender effects are in agreement (14). The finding that older individuals assessed their resilience as higher compared to younger people may suggest that they are able to deal with the pandemic in a more functional manner, possibly by drawing on cognitive, emotional, and behavior-based experiential contexts in which crises have played a role. Women and younger people report a higher psychological burden compared to high-risk groups (men and older people, [e10]). One possible explanation for this could be that younger people are more restricted in their everyday lives and that women generally report higher levels of psychological distress (e11).
The studies included in the systematic literature analysis identify numerous risk factors. Those particularly worthy of note include female sex, working in the health sector, and pandemic-specific factors (for example, contact with infected individuals) (e7). Awareness of these vulnerable groups opens up the potential of targeted prevention and low-threshold support (e.g., online services). In China, some hospitals developed and successfully implemented multimodal strategies for psychological interventions, which integrate measures not requiring personal contact, such as telephone hotlines and online platforms (20, 21). The results of the COSMO study also suggest that young age, female sex, having children, being a single parent, having a migrant background, as well as living alone or in a household with more than two people represent possible risk factors for psychomorbidity. We found it surprising that healthcare professionals did not report significantly higher psychological distress, in contrast to our analysis of the studies from China. However, this result should be evaluated with caution, since the type of healthcare occupation and whether these people were in contact with COVID-19 patients is unclear.
It becomes clear from some of the studies that social support, self-efficacy, psychoeducational measures, and providing up-to-date, positive and situation-specific information can protect against psychological distress. In line with this, interventional concepts that take into account these protective and resilience factors could be developed (Kunzler et al.: Mental health and psychosocial support strategies in highly contagious emerging disease outbreaks of substantial public concern: a systematic scoping review. PLOS ONE [submitted], ). However, there is still insufficient evidence from interventional studies in either the current pandemic or earlier pandemics.
This systematic literature analysis is based on the state of publications up to 16.04.2020. Since then, a number of European studies have been conducted that also reveal a picture of increased psychomorbidity. In a survey of German neurologists and psychiatrists conducted in early April 2020, approximately a third reported deep concern, high own risk of infection, and financial threat (e12). A nationwide survey of the Italian population in March 2020 found increased psychological distress compared to before the pandemic, with almost a fifth of respondents reporting pronounced symptoms of anxiety and around a third reporting pronounced symptoms of depression (e13).
To make a valid assessment of the psychological sequelae of the pandemic, it is necessary to conduct in particular population-representative studies, comparisons with data from before the SARS-CoV-2 pandemic, and longitudinal studies (Kunzler et al.: Mental health and psychosocial support strategies in highly contagious emerging disease outbreaks of substantial public concern: a systematic scoping review. PLOS ONE [submitted]).
On the basis of previous research on potentially traumatic life events, greater attention should be focused on resilience in the sense of positive individual trajectories (23, 24). Taking the findings presented in this article as a starting point, one could deploy psychological interventions, aimed in particular at self-efficacy, information strategies and their evaluation, opportunities for social support, and psychoeducational initiatives in the media, in order to minimize the negative effects of the SARS-CoV-2 pandemic and learn for future pandemics.
The present study has limitations that narrow down the conclusions that can be drawn. For the COSMO study, these include:
- The early timing of the survey in the course of the SARS-CoV-2 pandemic
- The short survey period
- The assessment of mental health by means of a combination of items from different questionnaires, for some of which norm values for the general population are lacking
- The fact that the sensitivity of BRS has not yet been validated with respect to changes in self-assessed resilience at different points in time
- The low response rate of under 20%, which limits the generalizability of the results to the German population.
Limitations of the systematic literature analysis include:
- The limited quality and lack of representativeness of the studies
- Lack of comparisons with norm data
- The questionable extent to which the results can be extrapolated to Germany
- Inconsistencies in the use of measurement tools and their cut-off values
- A potential publication bias
- The problematic use of the term “posttraumatic stress symptoms,” which leaves unclear the relationship to the concept of trauma and the diagnosis of a posttraumatic stress disorder according to ICD-10 (e14, e15).
We would like to thank the COSMO group (Cornelia Betsch, Lars Korn, Lisa Felgendreff, Sarah Eitze, Philipp Schmid, Philipp Sprengholz [Erfurt University], Lothar Wieler, Patrick Schmich [Robert Koch Institute], Volker Stollorz [Science Media Center Germany], Michael Ramharter [Bernhard Nocht Institute for Tropical Medicine], Michael Bosnjak [Leibniz Center for Psychological Information and Documentation], Saad B. Omer [Yale Institute for Global Health]).
Conflicts of interest statement
The authors state that no conflicts of interest exist.
Manuscript received on 11 May 2020, revised version accepted on 28 July 2020.
Translated from the original German by Christine Rye.
Dr. phil. Donya Gilan
Klinik für Psychiatrie und Psychotherapie, Universität Mainz
Leibniz-Institut für Resilienzforschung
Wallstr. 7, 55122 Mainz, Germany
Cite this as:
Gilan D, Röthke N, Blessin M, Kunzler A, Stoffers-Winterling J, Müssig M,
Yuen KSL, Tüscher O, Thrul J, Kreuter F, Sprengholz P, Betsch C, Stieglitz RD, Lieb K: Psychomorbidity, resilience, and exacerbating and protective factors during the SARS-CoV-2-pandemic—a systematic literature review and results from the German COSMO-PANEL. Dtsch Arztebl Int 2020; 117: 625–32.
For eReferences please refer to:
eMethods, eTables, eBox, eFigure:
Leibniz Institute for Resilience Research, Mainz, Germany:
Dr. phil. Dipl.-Psych. Donya Gilan, Manpreet Blessin, M.Sc., Dipl.-Psych. Angela Kunzler,
Dipl.-Psych. Jutta Stoffers-Winterling, Markus Müssig, M.Sc., Kenneth S. L. Yuen Ph.D.,
Prof. Dr. med. Oliver Tüscher, Prof. Dr. med. Klaus Lieb
Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Germany:
Dr. phil. Dipl. Psych. Donya Gilan, Nikolaus Röthke, Dipl.-Psych. Jutta Stoffers-Winterling,
Prof. Dr. med. Oliver Tüscher, Prof. Dr. med. Klaus Lieb
Department of mental Health, Johns Hopkins Bloomberg School of Public Health,
Baltimore, MD, USA: Dr. phil. Johannes Thrul
University of Mannheim & University of Maryland: Prof. Dr. rer. soc. Dipl.-Soz. Frauke Kreuter
Institute of media and communication sciences, University of Erfurt, Germany:
Philipp Sprengholz, M.Sc., Prof. Dr. phil. Cornelia Betsch
Faculty of Psychology, University of Basel, Switzerland: Prof. Dr. em. rer. nat. Dipl.-Psych.
Rolf Dieter Stieglitz
Human Neuroimaging Center, Focus Program Translational Neurosciences (FTN) of the Johannes Gutenberg University Mainz, University Medical Center Mainz, Germany: Kenneth S. L. Yuen Ph.D
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