key: cord-0756725-wt52wbdh
authors: Guan, Ming
title: Could the Associations of Changes in Living Arrangement with Mental Disorders Be Moderated or Mediated During COVID-19 Pandemic?
date: 2021-06-16
journal: Psychol Res Behav Manag
DOI: 10.2147/prbm.s302729
sha: 227870e53d9f979f019acaae049e43df8e794aac
doc_id: 756725
cord_uid: wt52wbdh

PURPOSE: Changes in living arrangement was one of the most well-established risk factors for mental disorders, but little evidence came from moderating or mediating effect during COVID-19 pandemic. This study aimed to determine whether associations of changes in living arrangement with mental disorders could be moderated or mediated during COVID-19 pandemic. METHODS: Data were a cross-sectional and international population-based survey data collected as part of theCOVID-19 pandemic. Participants included nationally representative general population probability samples of adults (≥18 years) during COVID-19 pandemic (N=16,784). Main mental measures were reflected by loneliness assessed by UCLA Loneliness Scale Version 3, anxiety assessed by Generalised Anxiety Disorder 2-item, and depressed mood assessed by The Patient Health Questionnaire-2 in the survey. With control variables, all the mediation models were conducted by Stata mode. Potential influencing effects of social contact and social support as moderators were analyzed using Hayes’s PROCESS macro. RESULTS: Among the participants, prevalence of mental disorders was high. Logistic regression indicated that changes in living arrangement had significant associations with anxiety (AOR=1.127, 95% CI: 1.018–1.249) and depression (AOR =1.142, 95% CI: 1.027–1.269). Mediation models indicated that indirect, direct, and total effects of changes in living arrangement on mental disorders through COVID-symptoms; change in alcohol use; and social contact were significant. Indirect, direct, and total effects of changes in living arrangement on loneliness and depression through social support were significant. Moderation analysis indicated that moderation model 1 in AF Hayes Process procedure was accepted. CONCLUSION: This study indicated that associations of changes in living arrangement with mental disorders could be mediated by COVID-symptoms, changes in alcohol use, social contact, and social support and moderated by social support during COVID-19 pandemic. The finding in this study might provide better understanding of the mechanisms by which social support might contribute to the resolving mental disorders.

In order to contain the transmission of the virus, a number of restrictive and effective measures changed the living arrangement of the general public. Many persons died of COVID-19, which also might change living arrangement of family members. 1 In order to reduce the person-to-person transmission risk of COVID-19, physical distancing, 2 population flow, 3 close contact, 4 and family cluster [5] [6] [7] were controlled and changed the living arrangement of the acquaintances. Simultaneously, those public health interventions including traffic restriction, home confinement, and centralized quarantine 8 were certain to change living arrangement in a family.

A substantial body of studies indicated changes in living arrangement including containment measures (isolation and quarantine) could lead to mental disorders. 9 Studies showed effects of containment measures (physical distancing and isolation) and lockdown 10 driven by COVID-19 on mental health of the general population. 11 Additionally, depression and probably anxiety, 12 suicidal thoughts, 13 intimate partner violence, 14 anxiety disorders, 15 depressive symptoms, 16, 17 and psychotic relapse 18 during COVID-19 quarantine were reported. In particular, first psychotic episodes reactive to stress in both general population 19 and healthcare professionals 20 were also reported. Speculatively, association between changes in living arrangement and mental disorders could be mediated by COVID-19 factors in the general public.

Currently, COVID-19 outbreak was leading to mental crisis globally. 21, 22 Mental disorders driven by COVID-19 in China, 23 Turkey, 24 Spain, 25 and America 26 were reported. Additionally, multiple cross-sectional studies indicated COVID-19 pandemic had a great psychological impact on the general public [27] [28] [29] and healthcare professionals. 30, 31 A review reported psychological symptoms due to the COVID-19 pandemic may be associated with disturbed sleep. 32 Another review reported that COVID-19 pandemic led to the direct neuropsychiatric consequences and the indirect effects on mental health. 33 Several current studies indicated social support could reduce psychological impact due to COVID-19. [34] [35] [36] [37] Speculatively, social contact and support could moderate or mediate the association between changes in living arrangement and mental disorders in the general public.

The purpose of this pilot study was to explore whether the associations of changes in living arrangement with mental disorders were moderated or mediated during COVID-19 pandemic. First, associations of changes in living arrangement with loneliness, anxiety, and depression could be confirmed. Second, mediating effects of COVID-19 test, COVID-symptoms, and change in alcohol use, social contact, and social support on the associations need to be demonstrated. Finally, this study would explore the moderating effects of the targeted associations by social contact and social support. The mechanism with those associations was important for the general public to assess the performance of COVID-19 management.

Data employed in this study were from COVID-19 Survey in Five National Longitudinal Studies. COVID-19 Survey in Five National Longitudinal Studies was an online survey of the participants of five national longitudinal cohort studies in May 2020. 38 

Exposures Changes in living arrangement and COVID-symptoms.

Changes in living arrangement were measured by the question: "Have there been any changes to the people you are living with since the Coronavirus outbreak?" Its response options were yes (=1) and no (=0). or body aches, fatigue, unusual loose motions or diarrhea, vomiting, loss of smell, loss of taste, skin rash, headaches, and others. Thus, response options of COVID-symptoms experienced were defined as yes (=1) and no (=0).

Alcohol use was defined by Alcohol Use Disorders Identification Test (AUDIT). 39 In the questionnaire, alcohol use before COVID-19 and alcohol use since COVID-19 were defined with the first two questions and the subsequent five questions. As for the first question: "In the month before the Coronavirus outbreak, how often did you have a drink containing alcohol?", its response options included "4 or more times a week (=1)", "2-3 times a week (=2)", "2-4 times per month (=3)", "Monthly or less (=4)", and "Never (=5)" and were recoded reversely. Likewise, the third question was: "Since the start of the Coronavirus outbreak, how often have you had a drink containing alcohol?" Its response options included "4 or more times a week (=1)", "2-3 times a week (=2)", "2-4 times per month (=3)", "Monthly or less (=4)", and "Never (=5)" and were recoded reversely. Similarly, regarding the final question: "Since the start of the Coronavirus outbreak, has a relative, friend, doctor or health worker been concerned about your drinking or advised you to cut down? ", its response options "yes (=1)" and "no (=2)" were recoded reversely. Thus, the total score of alcohol use since COVID-19 was obtained by summing the scores for seven items with the total score ranging from 7 to 32. After standardization, the difference between standardized score of alcohol use since COVID-19 and standardized score of alcohol use before COVID-19 referred to change in alcohol use, in which positive values denoted changed alcohol use.

Social contact was reflected by the five questions: "In the last seven days, on how many days did you meet up in person with any of your family or friends who do not live with you?", "In the last seven days, on how many days did you talk to family or friends you do not live with via phone or video calls?", "In the last seven days, on how many days did you keep in contact with family or friends you do not live with by email or text or other electronic messaging?"

In the last seven days, on how many days did you take part in an online community activity, e.g. an online community group, online chat group, street or neighbourhood social media group?

And "In the last seven days, on how many days did you give help to people outside of your household affected by Coronavirus or the current restrictions?" Their response options were "every day (=1)", "4-6 days (=2)", "2-3 days (=3)", "1 day (=4)", and "never (=5)". Then, social contact score was defined by summing the score for each of the 5 items with the total score ranging from 5 to 25. Furthermore, social contact was divided by yes (total score ≥16) and no (total score <16).

Social support was defined by Short Social Provisions Scale (3-items). 40 The Social Provisions Scale was measured by the three questions: "I have family and friends who help me feel safe, secure and happy", "There is someone I trust whom I would turn to for advice if I were having problems", and "There is no one I feel close to." Their response options were "very true (=1)", "partly true (=2)", and "not true at all (=3)". Before scoring, the response options of the third question were recoded reversely. Consequently, the total score of social support was obtained by summing the score for each of the three items with the total score ranging from 3 to 9. Social support was divided by yes (total score ≥ median=6) and no (total score <median=6).

Loneliness, anxiety and depression.

Loneliness was assessed by UCLA Loneliness Scale Version 3. 41 Four items from the 20-item UCLA loneliness scale were asked of all cohort members. UCLA Loneliness Scale was measured by the four questions: "How often do you feel that you lack companionship?", "How often do you feel left out?", "How often do you feel isolated from others?", and "How often do you feel lonely?" Their response options were "hardly ever (=1)", "some of the time (=2)", and "often (=3)". Consequently, the total score of loneliness was obtained by summing the score for each of the three items with the total score ranging from 4 to 12. Loneliness was divided by yes (total score ≥median=8) and no (total score <median=8). response options were "not at all (=1)", "several days (=2)", "more than half the days (=3)", and "nearly every day (=4)". Consequently, the total score of anxiety was obtained by summing the score for each of the two items with the total score ranging from 2 to 8. Anxiety was divided by yes (total score ≥median=5) and no (total score <median=5).

The secondary outcome of this study was depression. Depressed mood was assessed by The Patient Health Questionnaire-2. 43 Patient Health Questionnaire 2-item (PHQ-2) was measured by two questions: "Little interest or pleasure in doing things" and "Feeling down, depressed or hopeless". Their response options were "not at all (=1)", "several days (=2)", "more than half the days (=3)", and "nearly every day (=4)". Consequently, the total score of depression was obtained by summing the score for each of the two items with the total score ranging from 2 to 8. Depression was divided by yes (total score <median=5) and no (total score ≥median=5).

In the dataset, the response options with "Not applicable" and "No information" were cleaned as missing values using the listwise deletion method. 44 Descriptive statistics for the sample were calculated on the basis of chi-square test. The significant comparison difference was conducted between genders. Subsequently, associations of gender, changes in living arrangement, COVID-symptoms, social contact, and social support with mental state were conducted with logistic regressions.

Due to dichotomous variables, all the mediation models were conducted by STATA mode ldecomp. 45 Here, changes in living arrangement had an indirect effect on loneliness, anxiety, and depression through COVID-19 test (model 1), COVID-symptoms (model 2), change in alcohol use (model 3), social contact (model 4), and social support (model 5), respectively. Control variables in model 1 were gender, change in alcohol use, COVID-symptoms, social contact, and social support. Control variables in model 2 were exchange in alcohol use, COVID-19 test, social contact, and social support. Control variables in model 3 were gender, COVID-19 test, COVID-symptoms, social contact, and social support. Control variables in model 4 were gender, COVID-19 test, COVID-symptoms, change in alcohol use, and social support. Control variables in model 5 were gender, COVID-19 test, COVID-symptoms, change in alcohol use, and social contact.

In Figures 1-Figures 3 , the moderation analysis only could be performed by models 1, 2, and 3 in AF Hayes's PROCESS macro (SPSS version 3.0) for IBM SPSS version 24.0 (www.afhayes.com; www.guilford.com/p/ hayes3) in the case of binary variables. On the basis of permutation and combination knowledge, model 1 had six conceptual diagrams. Six and 18 conceptual diagrams were constructed in models 2 and 3, respectively. All the conceptual diagrams could be seen in Supplemental File. Here, mental state was loneliness, anxiety, and depression. Moderators were COVID-19 test, COVID-symptoms, change in alcohol use, social contact, and social support. Statistical analyses with p values <0.1 were considered significant. 

Demographic characteristics of the 16,784 participants are shown in Table 1 . The majority of the sample was female (61.04%). The percentages of COVID-19 test (2.66%), changes in living arrangement (17.20%), change in alcohol use (44.67%), social contact (32.53%), and social support (36.90%) were low. Notably, the prevalence of COVIDsymptoms (51.89%), loneliness (70.38%), anxiety (80.05%), and depression (81.09%) was high. There were significant gender differences among COVID-19 test, changes in living arrangement, change in alcohol use, COVID-symptoms, social contact, social support, loneliness, anxiety, and depression.

In But, no significant association of changes in living arrangement with loneliness and association of change in alcohol use with depression were observed.

In Table 3 , statistical outcomes of direct and indirect effects in logit models were reported. In model 1, changes in living arrangement had significantly negative total and direct effects and insignificant zero indirect effects on loneliness, anxiety, and depression through COVID-19 test. In model 2, changes in living arrangement had significantly negative total, direct, indirect and effects on loneliness, anxiety, and depression through COVID-symptoms. In model 3, changes in living arrangement had significantly negative total and direct effects and significant positive indirect effects on loneliness, anxiety, and depression through change in alcohol use. In model 4, changes in living arrangement had significantly negative total and direct effects and significant positive indirect effects on loneliness, anxiety, and depression through social contact. In model 5, changes in living arrangement had significantly negative total and direct effects and significant positive indirect effects on loneliness and depression through social support. Simultaneously, changes in living arrangement had significantly negative total and direct effects and insignificant positive indirect effects on anxiety through social support.

With the "PROCESS Macro for SPSS", detailed calculations were seen in Supplemental File. Among them, only empirical outcomes of conceptual diagram 5 exhibited significance (in Table 4 ). Thus, social support moderated the relationship between changes in living arrangement and anxiety. In the other empirical outcome of conceptual diagrams, there were not co-occurring significances of covariates and interactions. Accordingly, models 2 and 3 were rejected.

The primary finding of this study was associations of changes in living arrangement with mental disorders could be mediated and moderated during COVID-19 pandemic. Logistic regression indicated associations of gender, changes in living arrangement, COVID-symptoms, social contact, social support with mental disorders. DovePress support were not significant. Indirect, direct, and total effects of changes in living arrangement on mental disorders through COVID-symptoms, change in alcohol use, and social contact were significant. Indirect, direct, and total effects of changes in living arrangement on loneliness and depression through social support were significant. Regarding moderation analysis, this study indicated that the relationship the effect of changes in living arrangement on anxiety was moderated by social support. These associations provided hints for rethinking over COVID-19 management among the surveyed sample.

The outcomes of logistic regressions were in line with early studies. With respect to gender, a substantial body of studies reported the same results. 46, 47 Regarding the role of living arrangement in mental disorders, the research outcomes were in line with several prior studies. For example, living arrangement was found to be associated with loneliness among older adults 48 and depressive symptoms in children. 49 A study in Malaysia revealed that living arrangement directly, and indirectly through social support function, predicted life satisfaction for older adults. 50 This was in line with the result from an Oregon study that confirmed an association between respiratory symptoms and mental disorders among youth in the community. 51 Regarding social contact, this study was congruent with early studies that social contact could predict 52 and be related to 53 mental health. To my best knowledge, this was the first study to report the relationship between COVID-symptoms and mental disorders during COVID-19 pandemic. Till now, there was little knowledge to explain the relationship. It may be possible that the COVID-symptoms are important hints of risk for COVID-19 infection which was exposed to mental disorders. Regarding mediation analysis, the research outcome could be explained partially by early studies. For example, a Chinese study indicated that the effect of social support on mental health could be partially mediated by resilience and moderated by age group. 54 Furthermore, a recent Israelis study demonstrated that young subjective age might weaken the COVID-19-related loneliness-psychiatric symptoms association among older adults during the COVID-19 pandemic. 55 Regarding moderation analysis, this study indicated that the effect of changes in living arrangement on anxiety was moderated by social support. This could be explained by a study that social support could help people be adapted to COVID-specific needs of a prolonged isolation and postisolation. 56 To my best knowledge, the finding in this study enriched the knowledge of moderating effects of social support. Some early studies reported social support moderated the impact of neuroticism and extraversion on mental wellbeing, 57 associations among discrimination, mental health, and sociality, 58 and direct association between workplace bullying and mental distress. 59 With regard to the current policy effectiveness, the findings in this study indicated that "Psychological First Aid" technique initiated by the World Health Organization 60 seemly achieved no good results. But, a longitudinal study in China reported that there was a statistically significant longitudinal reduction in the psychological impact of general population during the COVID-19 epidemic. 61 Thus, effective methods could be learned.

Regarding academic contributions, this study provided fresh insights into the fields of COVID-19 management, changes in living arrangement, and mental disorders. First, 

This empirical study did provide recommendations as well as clinical considerations for managing adverse events. The COVID-19 pandemic still represented one of the most stressful events of recent times. The general public was vulnerable to adverse mental health impacts of changes in living arrangement. Thus, the prevalence of mental disorders and associated factors during COVID-19 pandemic should be highlighted. Clinically, healthcare Note: *** and **Indicated 1% and 5% significance level, respectively. 

professionals should treat changes in living arrangement as the psychological determinant and concern posttraumatic stress symptoms. The current findings identified the increase in social support could reduce anxiety state in the general public during COVID-19 pandemic.

There were two main strengths in the present study. First, a large multinational sample allowed sufficient statistical power to draw conclusions. Second, two statistical softwares with a number of possible mediating and moderating models were employed to explore the targeted associations. There were three main limitations in this study. First, the findings from a cross-sectional data could not produce causal relationships. Second, the analysis of data across five countries yielded regional research outcomes which could not reflect global generalization. Third, this study did not use standardized scales to evaluate the changes in lifestyle caused by the pandemic, such as the Short Multidimensional Inventory Lifestyle Evaluation-Confinement, 62 which could worsen the research rigor of this study.

In conclusion, this study reported the association between changes in living arrangement and anxiety moderated by social support and medicated by COVID-symptoms, change in alcohol use, and social contact during COVID-19 pandemic. This study found that social support was not associated with anxiety or depression. Further research was needed to clarify the causative factors underlying these differential relationships during COVID-19 pandemic.

Data can be obtained via https://beta.ukdataservice.ac.uk/ datacatalogue/studies/study?id=8658.

This study used publicly available dataset. So, it is unnecessary to be proved by ethics committee.

The author of this paper would like to acknowledge the very helpful comments of the reviewers on the original submission. 

Ming Guan is head of the International Issues Center and Family Issues Center at Xuchang University. The author reports no other conflicts of interest in this work.

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