key: cord-0748884-3qgknhmv
authors: Plomecka, M. B.; Gobbi, S.; Neckels, R.; Radzinski, P.; Skorko, B.; Lazerri, S.; Almazidou, K.; Dedic, A.; Bakalovic, A.; Hrustic, L.; Ashraf, Z.; Es haghi, S.; Rodriguez-Pino, L.; Waller, V.; Jabeen, H.; Alp, A. B.; Behnam, M. A.; Shibli, D.; Baranczuk Turska, Z.; Haq, Z.; Qureshi, S. U.; Strutt, A. M.; Jawaid, A.
title: Mental Health Impact of COVID-19: A global study of risk and resilience factors
date: 2020-05-09
journal: nan
DOI: 10.1101/2020.05.05.20092023
sha: 8a784c9ee4dd3205a0a3106e4480d0ca0ef6b8c5
doc_id: 748884
cord_uid: 3qgknhmv

This study anonymously screened 13,332 individuals worldwide for psychological symptoms related to Corona virus disease 2019 (COVID-19) pandemic from March 29th to April 14th, 2020. A total of n=12,817 responses were considered valid with responses from 12 featured countries and five WHO regions. Female gender, pre-existing psychiatric condition, and prior exposure to trauma were identified as notable riskfactors, whereas optimism, ability to share concerns with family and friends like usual,positive prediction about COVID-19, and daily exercise predicted fewer psychologicalsymptoms. These results could aid in dynamic optimization of mental health services during and following the COVID-19 pandemic.

4 manifestations as its effects on the nervous system are increasingly reported in patients who do not exhibit prominent respiratory tract symptoms. 18 A number of studies from China have reported significant increases in symptoms of anxiety, distress, and risk of PTSD in students and health professionals assessed during the COVID-19 pandemic. 13, [19] [20] [21] [22] [23] [24] [25] A timely assessment on a global scale is paramount to display the mental health impact of the COVID-19 pandemic. With this data, health systems can strive to improve mental health services to reduce the long-term morbidity and mortality related to the COVID-19 crisis. Furthermore, this information could aid policymakers in improving the compliance of masses to the lock-down measures. 7

To address this, we assembled a team of health professionals (neuroscientists, psychiatrists, psychologists, data scientists, and medical students) across all continents to develop a global study on the mental health impact of COVID-19. This study employs a fully anonymous online survey screening individuals in multiple countries for indicators and/or risk of general psychological disturbance, post-traumatic stress disorder (PTSD), depression, suicidal ideation, and concerns about physical health and appearance. The prevalence of these conditions was then cross-analyzed with participants' demographics, opinions/outlooks, personality traits, current house-hold conditions, previous psychiatric disease history, and factors associated with COVID-19 to identify specific risk and resilience factors. We found alarming global trends for general psychological disturbances, risk for PTSD and depression, and suicidal ideation that were specifically predicted by participant demographics, personality traits, house-hold conditions, previous psychiatric disease and/or risk factor history and prediction about COVID-19 resolution.

The study comprised a cross-sectional electronic survey-based assessment of individuals above the age of 18 years willing to participate in the study. The anonymous survey was conducted among participants from diverse demographic groups across continents using standardized self-report scales to screen for general psychological disturbance, risk for 5 PTSD, and symptoms of depression. Specific responses were also independently assessed to screen for suicidal ideation and concerns for physical health and appearance. The survey was available online (placed on Google Forms platform) for a period of 15 consecutive days starting 18:00 Central European Time on March 29 th , 2020 and concluding on 18:00 Central European Time on April 14 th , 2020.

The questionnaire was developed via close consultation between a neuroscientist, a neuropsychologist, a psychiatrist, a data scientist, and a psychiatry clinic manager. The questionnaire included closed-ended questions that assessed participant characteristics and opinions, and screened for neuropsychiatric conditions through standardized and validated self-report scales. The questionnaire prototype was prepared in English (Appendix 1) and translated into 10 additional languages (Arabic, Bosnian, French, German, Greek, Italian, Persian, Polish, Spanish, and Turkish; Appendix 2). The translation was performed by bilingual native speakers and vetted by volunteers native to those countries. The feasibility of each questionnaire was confirmed using pilot studies comprised of 10 participants each. These responses were excluded from the final analysis.

The questionnaires (Appendix 1) included a section on participant demographics (age, gender, country, residential setting, educational status, current employment status) house-hold conditions (working/studying from home, home isolation conditions, pet ownership, level of social contact, social media usage, time spent exercising), COVID-19 related factors (knowing a co-worker, friend, or family member who tested positive for or demised due to COVID-19, prediction about pandemic resolution), personality traits (level of optimism, level of extroversion), previous history of psychiatric disease and/or trauma, previous exposure to human crisis, and level of satisfaction with actions of the state and employer during the current crisis. All questionnaires were rated on binary (yes/no) responses or Likert-type scales.

The other sections contained general health assessment based on WHO Self-Reporting Questionnaire-20 (SRQ), Impact of Event Scale (IES), and Beck's Depression Inventory 6 II (BDI). 24, 26, 27 These scales were chosen based on their common usage and efficacy in previously employed works studying the psychological impact of human crises, including the SARS epidemic. 28-36 IES was purposefully adjusted to assess the impact of an ongoing event rather than a past event. For this purpose, the past tense was converted into the present tense in each question without changing the subject matter. This adjustment was performed in consultation with an independent neuropsychologist not involved in the study. For all scales, participants were prompted to think of and report their physical and psychological state during the preceding week.

Informed consent was obtained from each participant to allow anonymous recording, analysis, and publication of their answers. The data was collected in a completely anonymous fashion without recording any personal identifiers. This strategy ensured that the confidentiality of the participants was maintained throughout all phases of the study.

The study procedures were reviewed and approved by University of Zurich Research Office for Scientific Integrity and Cantonal Ethics Commission for the canton of Zurich 

Using a non-randomized referral sampling (snowball sampling) method, participants were contacted by a team of 70 members (study authors and volunteers that have been acknowledged in the acknowledgement section) using electronic communication channels including posts on social media platforms, direct digital messaging, and personal and professional email lists. A concerted effort was made to ensure maximum participation from the countries that had the highest number of cases and >100 daily new cases (as reported on www.worldometers.info) as of March 29 th , 2020. These countries included USA, Spain, Italy, France, Germany, UK, Iran, Turkey, and Switzerland. China 7 was not included in this list (from here on referred to as the featured countries) due to the number of daily new cases being <100 during the data collection period. In addition to the most severely affected countries, a concerted effort was made to include two countries each from the 11 th -20 th (Canada and Poland), and a country each from the 20 th -30 th (Bosnia and Herzegovina), and 30 th -40 th (Pakistan) most affected countries in the featured list. For the featured countries, national coordinators also reached out to at least 10 social media influencers and requested their voluntary help with the diffusion of the survey. The overall number of responses obtained via social media influencers was primarily a reflection of those from Pakistan, Spain, Switzerland, and USA. The data collection procedures were repeated at least thrice during the data collection period (March 29 th -April 14 th , 2020) with the aim to ensure participation of at least 250 participants each from the list of featured countries. This aim was achieved in all the featured countries with the exception of the UK, which was subsequently excluded from the featured list. For the non-featured countries, where the number of responses was less than 250 per country, the responses were grouped together based on the WHO regions (African Region AFRO, Region of the Americas PAHO, South East Asia Region SEARO, European Region EURO, East Mediterranean Region EMRO, and Western Pacific Region WMRO). WHO AFRO region was excluded from the analysis due to total number of responses being less than 250.

The data was collected exclusively online for participants under 60 years of age. For participants who were 60 or above, a special provision was allowed for assistance in recording their responses online as older adults are often not comfortable with virtual platforms. 37

Our data collection strategy resulted in a total of 13,332 responses. Surveys completed by participants who were younger than 18 (n=34), those with missing responses for all dependent variables (n=112), filled the second time (n=325), missing geographic location (n=20), and from WHO AFRO region (n=24) were excluded from the final analysis. When the responses were missing for individual items, the missing data were considered null and excluded from the analysis for that particular variable. The number of participants for each of the featured countries and the regions encompassing the non-featured countries is represented in the Supplementary item S1.

The snow-ball sampling method precludes us from inferring the response rate of the study. However, a minimum of 250 participants from the featured countries and the WHO regions with the non-featured countries was chosen to ensure that any within-group differences could be elucidated with a reasonable statistical confidence and an error margin <5%.

All statistical analyses were performed using R version v.3. 6 Logistic regression was performed to generate odds ratios (ORs) for SRQ, IES, and BDI using the following categorization scheme; SRQ: 0 = normal (0-7 points), 1 = concern for general psychological disturbance (8-20 points); IES: 0 = normal (0-23 points), 1 = PTSD is a clinical concern (24-32 points), 2 = threshold for a probable PTSD diagnosis (33-36 points), 3 = Severe condition (high enough to induce immunosuppression) (37 points).

For generating ORs, the variables were regrouped as 0 = no concern versus any type of concern (1/2/3); BDI: 0 = These ups and downs are considered normal (1-10 points). 1 = Mild mood disturbance (11-16 points), 2 = Borderline clinical depression. (17-20 points), 3 = Moderate Depression (21-30 points), 4 = Severe Depression (31-40 points), 5 = Extreme Depression (>40 points). For generating ORs, the variables were regrouped as 0 = no concern versus any type of concern (levels 1/2/3/4/5). Cut-offs for SRQ, IES, and BDI were defined using least stringent thresholds for each of these measures from previous literature to ensure high sensitivity of the screening. [24] [25] [26] [27] [28] Furthermore, three separated OR analyses were performed for suicidal ideation, and concerns about physical health and appearance based on relevant questions from BDI. For these models, reference level was set to 0= absence of symptom that was compared to presence of symptom (varying severity levels of the symptom regrouped into one category).

Finally, correlations between SRQ, IES, and BDI were performed through Pearson's correlation test and illustrated as x~y plots. All statistical analyses were performed by the analysis team comprising MP, SG, PR, and AJ in consultation with ZB. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

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Unadjusted analyses of SRQ, IES, and BDI scores between different participant demographics/characteristics showed significantly (p<0.017) greater prevalence of psychological symptoms in participants who were female, unemployed, working remotely from home, dissatisfied with the response of their employer/state to COVID-19, homeisolated alone, with a pet, interacting with friends/famiy less than usual, using social media more than usual, and in those with less-than-usual ability to share concerns with friends/family. Significantly (p<0.017) higher scores on SRQ, IES, and BDI were also seen in participants who self-reported as being pessimist or introvert, not feeling in control during COVID-19, and having an overall negative prediction about COVID-19 resolution.

Means and standard deviations for all comparisons are presented in Main Item 2.

Adjusted analysis using different general linear models for each of the questionnaires is reported in Main Item 3. Across all three questionnaires, we found the following relevant risk factors for general psychological disturbance, PTSD, and depression: psychiatric condition that worsened during the COVID-19 pandemic (SRQ mean-coefficient: 0.36, 95 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

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Having an optimistic attitude, positive prediction about COVID-19, and being able to share concerns with family/friends decreased SRQ, IES, and BDI scores, indicating the protective effect of these factors for general psychological disturbance, PTSD and depression (as shown in Main Items 3 and 4). Furthermore, daily physical activity/sport is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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as a health professional is a resilience factor against depression during the COVID-19 pandemic.

Responses to three relevant questions from BDI indicating suicidal ideation and concerns about physical health and physical appearance were analyzed separately through logistic regression models.

Worsening of pre-existing psychiatric condition and past exposure to trauma predicted increased suicidal ideation ( 

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The continuous scores of all responses on SRQ, BDI, and IES were also analyzed by Pearson's correlations using all possible combinations on x~y plotting (SRQ vs. IES, IES vs. BDI, BDI vs. SRQ). All combinations yielded significant correlations with the strongest correlation (R=0.79) between BDI and SRQ (Supplementary Item S9).

This study highlights a significant impact of COVID-19 pandemic on mental health worldwide. Baring a few outliers, participants across the 12 featured countries and other countries clustered into five WHO regions had scores exceeding the mild-risk threshold for general psychological disturbance, PTSD, and depression, as determined by standardized scales. Furthermore, an alarming fraction (16.2%) of the participants reported experiencing some level of suicidal ideation. A prominent fraction (41%) of the participants also expressed concerns about their physical health and appearance, which is known to accompany other forms of psychological distress. 34, 38 In addition to reporting prevalence, a major aim of this study was to identify specific risk and resilience factors for psychological perturbations during the current COVID-19 crisis.

Worsening of a pre-existing psychiatric condition, female gender, exposure to trauma before age 17, and working remotely predicted higher risk of general psychological disturbance, PTSD, depression, and increased concerns about physical health and appearance. Additionally, considering oneself an introvert was associated with heightened risk of general psychological disturbance and depression; being unemployed, living alone, and limited interaction with family and friends also increased the risk for depression. Pre-existing psychiatric conditions and previous exposure to traumatic events predicted suicidal ideation. An overall protective effect against all major psychological perturbations was observed for the following factors; increasing age, considering oneself an optimist, positive prediction about COVID-19 outcome, ability to share concerns with family and friends like usual, daily physical exercise/sport for 15 minutes or more, and being satisfied with the actions of employer/state in response to COVID-19. Furthermore, being a health professional was associated with lower general psychological disturbance, depression, suicidal ideation and concern for physical health, . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 9, 2020. . https://doi.org/10.1101/2020.05.05.20092023 doi: medRxiv preprint and like-usual social media usage was associated with less concern for physical appearance.

To the best of our knowledge, this study is the first worldwide assessment of the mental health effects of COVID-19. Previous studies on the psychological impact of COVID-19 have been exclusively from China 13,19-25 with the exception of one study in India. 39 The largest of these studies (n=52,730) that surveyed voluntary public participants, reported symptoms of psychological distress in almost one-third of the participants according to the peri-traumatic distress index. 40 Another notable study, on health professionals (n=1,255), revealed depression, anxiety, and symptoms of general distress in almost half of participants, and sleep disturbances in almost 8%. 13 One-third of the participants in a Chinese study on college students (n=7,143) in the Hubei province reported symptoms of anxiety. 25 Some of our observations are supportive of findings in these studies, such as female gender, living alone, and negative prediction about COVID-19 outcome arising as risk factors for psychological perturbations. However, our study identifies several unique risk and resilience factors that were not investigated previously.

Parallels can also be drawn between our study and existing research on the psychological effects of the SARS and other previous epidemics. These studies reported PTSD, anxiety, distress, anger, and confusion as major sequelae of the epidemic and quarantine measures. 35,41-43 It has previously been reported, however, that very few studies investigated specific risk or protective factors 7 for these mental health disturbances. One notable study showed longer quarantine duration, boredom, financial instability, stigma, inadequate resources and information deficit to exacerbate the negative psychological impact from the SARS outbreak. In noteworthy contrast to our work, the study was performed several months after the epidemic had occurred. 44 Identification of specific risk and resilience factors is an essential first step for developing strategies to mitigate the negative psychological impact of COVID-19 at a regional and global level. For example, selective vulnerability of females indicated in this study warrants further investigation for both the contributing factors and the resulting implications of such increased risk. These include social factors such as increased reporting of domestic violence in relation to COVID-19 45 , possible caregiver stress, and the impact of changes in roles and responsibilities secondary to the current health . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 9, 2020. . https://doi.org/10.1101/2020.05.05.20092023 doi: medRxiv preprint emergency. Furthermore, increased risk of psychological perturbations in individuals with pre-existing psychiatric conditions and/or trauma exposure necessitates the initiation and/or expansion of mental health support systems available remotely. 40 Emerging evidence now supports the efficacy of web-and social-media based interventions in promoting mental health of masses focusing on paradigms based on mindfulness, positive psychology, and exercise. 46-48 Such interventions could be developed at the governmental and institutional levels and delivered to the masses via main-stream and social media. Indeed, media outlets could also play a major role in promoting optimism and a positive attitude towards COVID-19 resolution, both of which were identified in our study as important resilience factors. One example of media positivity could be reporting on 'number of active cases' rather than 'number of new cases', as this would also portray 'number of recoveries'. It is of notable possibility that this method could not only serve to reduce psychological distress and hopelessness, but could also provide a more accurate estimate of the burden on health systems. Furthermore, the association between remote working with increased psychological symptoms calls for optimization of the work-fromhome settings and a greater emphasis on the general well-being of employees. This is further corroborated by the observation that participant satisfaction with the employerresponse to the COVID-19 pandemic is associated with reduced psychological symptoms in this study. Finally, the association of suicidal ideation with both pre-existing psychiatric condition and previous trauma exposure merits awareness efforts to inform the public about these risks. Such a finding could also warrant targeted interventions by mental health entities to mitigate the risk of suicide in these vulnerable populations.

An intriguing finding of this study is a mild protective effect of increasing age against general psychological disturbance, PTSD and depression. We recognize the possibility that this could be related to the study procedures. As the elderly are less comfortable with the use of electronic tools, a special provision was allowed for them to use assistance for recording their answers. However, this could have a confounding effect as older adults can be reluctant to openly report psychological symptoms. 49 Additionally, the utility of one of our assessment tools, SRQ, in detecting psychological disturbances in the elderly has been previously challenged. 50 Notably, a Chinese study also showed that adults aged 18-30 are most vulnerable to negative psychological effects of COVID-19 40 as seen in a vast . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 9, 2020. . https://doi.org/10.1101/2020.05.05.20092023 doi: medRxiv preprint majority of our participants as well. Therefore, it is plausible that older adults are indeed less affected psychologically by COVID-19 because of their lesser reliance on social media, which another Chinese study found to be associated with increased anxiety and depression during the COVID-19 outbreak. 13 This research has several strengths. This study employed the 2 nd largest sample size to The study also has potential limitations that warrant consideration when interpreting the results. First, the study employed a non-randomized sampling strategy. While this method has certain disadvantages, we hope that our results will catalyze the development of more studies on this essential topic that could be conducted by global outlets such as WHO and the European Union (EU) on a world-or continent-wide scale. Second, the data collection was exclusively done in an online format that may exclude those less-versed in . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 9, 2020. In conclusion, this effort highlights a significant impact of the COVID-19 pandemic at a regional and worldwide level on the mental health of individuals and elucidates prominent associations with their demographics, history of psychiatric disease risk factors, household conditions, personality traits, and attitude towards COVID-19. These results could serve to inform health professionals and policymakers across the globe, aiding in dynamic optimization of mental health services during and following the COVID-19 pandemic, and reducing its long-term morbidity and mortality. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 9, 2020. . https://doi.org/10.1101/2020.05.05.20092023 doi: medRxiv preprint 20 editing. AJ contributed in conceptualization, questionnaire development, study approval, data collection, data analysis, data visualization, manuscript writing, review, editing, project administration and supervision. All authors have reviewed and approved the final draft.

The authors declare no competing interests.

Data and materials availability: All data presented in the main and supplementary items are deposited on the repository below and are available for verification upon request.

https://osf.io/3vupe/?view_only=80f71b6f0c8d49b08573ea12eab10d33

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The copyright holder for this preprint this version posted May 9, 2020. Significant differences (p-value threshold set to <0.017 after multiple-comparisons . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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"Borderline", 17-20 points, Borderline clinical depression; Mld -"Mild", 11-16 points, Mild mood disturbance; Nrm -"Normal", 1-10 points, Considered normal For SRQ: Con -"Concern", 11-20 points, Clinical concern for General Psychological Disturbance; Nrm -"Normal", 0-10 points For IES: Sev-"Severe", 37+ points, symptoms high enough to suppress the immune offs used are as follows: for SRQ normal/concern (0-17, 8-20 points); for IES normal/concern/PTSD/severe (0-23, 24-32, 33-36, 37+ points); for BDI 15 normal/mild/borderline/moderate/severe/extreme (1-10, 11-16, 17-20, 21-30, 31-40, 40+ points). The plots include the total number and %age of participants in each category and the statistical outcomes from the chi-square test.

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The copyright holder for this preprint this version posted May 9, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 9, 2020. . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted May 9, 2020. Item S1 Number of participants per country and WHO region . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 9, 2020. . https://doi.org/10.1101/2020.05.05.20092023 doi: medRxiv preprint Item S2 Differences across countries for SRQ, IES, and BDI scores.

The boxplots show the distribution of scores for each country with the visualization of five summary statistics (minimum, maximum, median, first quartile, third quartile), and all outliers individually. Countries with significantly different scores are indicated on the left-hand side. The results were obtained performing pairwise comparisons with a nonparametric Wilcox test. **** p< 0.0001, *** p < 0.001, ** p < 0.01, * p < 0.05, ns= nonsignificant, B&H= Bosnia and Herzegovina.

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The map presents mean scores in the question from BDI assessing suicidal ideation (scale 0-3). For this illustration, varying levels of suicidal ideation (1-3) are grouped together as 1, i.e., 0= no suicidal ideation, whereas 1= any suicidal ideation. The mean scores are calculated separately for each of the featured countries, and for each of WHO regions using this binary classification for suicidal ideation.

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The copyright holder for this preprint this version posted May 9, 2020. BDI . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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Logistic regression was performed to generate odds ratios (ORs) for SRQ, IES, and BDI using the following categorization scheme; SRQ: 0 = normal (0-7 points), 1 = concern for general psychological disturbance (8-20 points); IES: 0 = normal (0-23 points), 1 = PTSD is a clinical concern (24-32 points), 2 = threshold for a probable PTSD diagnosis (33-36 points), 3 = Severe condition (high enough to induce immunosuppression) (37+ points). For generating ORs, the variables were regrouped as 0 = no concern versus any type of concern (1/ generating ORs, the variables were regrouped as 0 = no concern versus any type of concern (levels 1/2/3/4/5). Only the factors that survived step BIC models comparison are listed. OR >1 indicate increased risk and OR<1 indicates protective effect.

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The copyright holder for this preprint this version posted May 9, 2020. 9308.83 *** p < 0.001; ** p < 0.01; * p < 0.05.

Presentation of the odds ratios (ORs) for suicidal ideation based on the relevant question from BDI. BDI question screening suicidal ideation is rated on likert-type scale Concern about physical health . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 9, 2020. *** p < 0.001; ** p < 0.01; * p < 0.05.

Presentation of odds ratios for concern about physical health based on the relevant question from BDI. BDI question screening concern for physical health is rated on likert-type scale (0-3) indicating increasing concern for physical appearance. For this analysis, logistic regression was performed regrouping the variables as 0 = no concern versus any concern (1/2/3). Only the factors that survived step BIC models comparison are listed. OR >1 indicates risk and OR<1 indicates protective effect.

Concern about physical appearance . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 9, 2020. *** p < 0.001; ** p < 0.01; * p < 0.05.

Presentation of odds ratios for concern about physical appearance based on the relevant question from BDI. BDI question screening concern for physical appearance is rated on likert-type scale (0-3) indicating increasing concern for physical appearance. For this analysis, logistic regression was performed regrouping the variables as 0 = no concern versus any concern (1/2/3). Only the factors that survived step BIC models comparison are listed. OR >1 indicates risk and OR<1 indicates protective effect.

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These plots show Pearson's correlation values for all the possible pairs of the three scales used, i.e., SRQ vs. IES, IES vs. BDI, and BDI vs. SRQ. All the correlations are statistically significant and range from 68% to 79% correlation.

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Coronavirus disease 2019 ( COVID-19 ) -situation report 90

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