key: cord-0957650-0012g4t9
authors: Goularte, Jeferson Ferraz; Serafim, Silvia Dubou; Colombo, Rafael; Hogg, Bridget; Caldieraro, Marco Antonio; Rosa, Adriane Ribeiro
title: COVID-19 and mental health in Brazil: psychiatric symptoms in the general population
date: 2020-09-30
journal: J Psychiatr Res
DOI: 10.1016/j.jpsychires.2020.09.021
sha: f78a19404a7bc2d7a6aaf48370dc867a1043cf9e
doc_id: 957650
cord_uid: 0012g4t9

Public health interventions at general population level are imperative in order to decrease the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), but they may contribute to widespread emotional distress and increased risk for psychiatric illnesses. We report on the results of an investigation into the occurrence and determinants of psychiatric symptoms among the Brazilian general population (N=1996). We assessed sociodemographic variables and general mental health (DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure), depression (PROMIS depression v.8a), anxiety (PROMIS anxiety v.8a), and post-traumatic stress symptoms (Impact of Event Scale-IES-R scale) using an online web-based survey. Anxiety (81.9%), depression (68%), anger (64.5%), somatic symptoms (62.6%) and sleep problems (55.3%) were the most common psychiatric symptoms. Younger age, female gender, low income, lower level of education, longer period of social distancing, and self-reported history of previous psychiatric illness were strongly associated with higher severity of symptoms. Our results support the negative impact of the COVID-19 pandemic on the mental health of the Brazilian population. The high prevalence of psychiatric symptoms observed in our sample indicates that the mental health impact of the COVID-19 pandemic should be considered a public health problem in Brazil. The health systems and individual clinicians must be prepared to offer and implement specific interventions in order to identify and treat psychiatric issues.

In December 2019, coronavirus disease was first recognized as a disease caused by the severe acute respiratory syndrome coronavirus with the main infection site in Wuhan, Hubei Province, China .

Initially, the disease was believed to be confined only to this initial area, but it quickly spread worldwide and there have been now 15,232,830 confirmed cases of COVID-19, and 623,507 people had died around the world from COVID-19 (until 23 rd July 2020) (Dong et al., 2020) . In Brazil, the government declared a state of emergency on 3rd of February 2020 (Ministry of Health, 2020a) , with the first case of COVID-19 reported on 26th of February 2020 (Dong et al., 2020) . By 19th of May, COVID-19 had spread to every region in Brazil (Ministry of Health, 2020b) , with a total of 125,502 deaths by 5th of September (Dong et al., 2020) .

Public health interventions that require social distancing, community control, and business and school closures, have been implemented in Brazil and other countries around the world in order to decrease transmission of the virus. However, experience from previous disease showed that social distancing and other interventions that disrupt day-to-day normal activities are associated with the development of acute stress disorder symptoms (Brooks et al., 2020) . Indeed, individuals in quarantine reported higher prevalence of psychological symptoms such as emotional disturbance, depression, stress, low mood, irritability, insomnia, and posttraumatic stress symptoms than those who had not been in quarantine (Brooks et al., 2020) . Furthermore, fear of infection, frustration and boredom, insufficient supplies and financial losses are among the major contributors to the widespread emotional distress and increased risk for psychiatric illnesses associated with COVID-19 (Brooks et al., 2020) . Therefore, mental health burden and an increase in use of mental health services are expected as a consequence of this pandemic (Druss, 2020; Torjesen, 2020) .

Several studies have investigated the mental health of the general population during the ongoing pandemic (Xiong et al., 2020) ; for instance, Wang et al. showed a higher prevalence of depression, anxiety, and perceived stress in a Chinese population during the COVID outbreak . Similarly, another Chinese study reported that one quarter of subjects had acute stress, and more than one quarter had depression, anxiety, and insomnia, suggesting the COVID-19 pandemic has a negative impact on mental health . However, most of the studies in this field have been conducted in China Shi et al., 2020; and

Italy (Rossi et al., 2020) , and there is no research data assessing the psychological impact of the COVID-19 outbreak in Brazil (Xiong et al., 2020) . Therefore, the present study investigates the prevalence and determinants of psychiatric symptoms among the Brazilian general population during the peak of the pandemic.

We used a cross-sectional web-based survey, using an anonymous online questionnaire spread via social networks using a convenience sampling strategy. The data were collected between 20th of May and 14th of July, 2020, a peak period of COVID-19 contagion in Brazil. Approval for this study was obtained from the local institutional review board at Hospital de Clínicas de Porto Alegre. Online informed consent was obtained from the participants. The investigation was carried out in accordance with the latest version of the Declaration of Helsinki. The online questionnaire consisted of sociodemographic variables, questions to assess knowledge regarding COVID-19, and physical and mental health status, and history of previous psychiatric disorder including anxiety and mood disorders and psychosis based on a yes/no question.

The knowledge questionnaire consisted of 10 questions regarding the clinical characteristics and prevention of COVID-19. A correct answer was assigned 1 point and an incorrect/unknown answer was assigned 0 points. The total knowledge score J o u r n a l P r e -p r o o f ranged from 0 to 10, with a higher score denoting a better knowledge of COVID-19 (Zhong et al., 2020) .

For a general assessment of mental health, we used the DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure, which assesses 13 psychiatric domains (depression, anger, mania, anxiety, somatic symptoms, sleep problems, memory, repetitive thoughts and behaviors, dissociation, personality function, suicidal ideation, psychosis, and substance use) over the previous 2 weeks. Each item is rated on a 5point Likert scale (0= none or not at all; 1= slight rare, less than a day or two; 2= mild or several days; 3= moderate or more than half the days; and 4= severe or nearly every day). A rating of mild (i.e, 2) or greater on any item within a domain, or in the case of substance use, suicidal ideation, and psychosis, a rating of slight (i.e. 1) or greater, indicates symptomatology in this domain requiring further assessment.

The severity of stress, anxiety, and depression was measured as follows:

a) The Impact of Event Scale-Revised (IES-R) is a self-rated, 22-item questionnaire divided in three domains (avoidance, intrusion, and hyperarousal), which evaluates the distress caused by a traumatic event (Caiuby et al., 2012) . Each item is rated on a 5-point scale (0=not at all; 1=a little bit; 2=moderately; 3=quite a bit; 4=extremely). The IES-R total score is the sum of the average of each domain. A total score greater than 5.6 indicates psychological stress. 

c) The PROMIS anxiety assesses self-reported fear (fearfulness, panic), anxious misery (worry, dread), hyperarousal (tension, nervousness, restlessness), and somatic symptoms related to arousal (racing heart, dizziness).

Both PROMIS instruments used consist of an 8-item questionnaire that assesses symptoms over the previous seven days, with items rated on a 5point scale (1=never; 2=rarely; 3=sometimes; 4=often; 5=always). All PROMIS scores were presented as T-scores calculated by the Health Measures Scoring Service (https://www.assessmentcenter.net/ac_scoringservice) from the raw sum score, using T-scores from United States general population. The T-score is the standardized score, with a mean of 50 and standard deviation of 10. For depression and anxiety, a T-score lower or equal to 55 indicate no significant symptoms, higher than 55 to 60 indicate mild symptoms, higher than 60 to 70 indicate moderate symptoms, and higher than 70 to 84.1 indicate severe symptoms.

Descriptive statistics (number and %) were used to present sociodemographic characteristics, chronic medical diseases, and previous psychiatric disorders. Days of social distancing, age, score of Knowledge COVID-19 Scale, score of IES-R, PROMIS

Depression T-Score, and PROMIS Anxiety T-Score were reported as mean and standard deviation. The psychiatric symptoms according to the DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure were reported as percentages of cases with a positive screening. We used linear regression to identify potential associations of sex, age, marital status, household income, days of social distancing, previous psychiatric disorders, and education level with depression, anxiety, and stress.

Analyses were conducted in SPSS version 18. Statistical significance was set at P < .05, and all tests were 2-tailed.

A total of 1996 individuals completed the survey. Of the total sample, 1676 (84.5%) were female, the mean (SD) age was 34.22 (12.57) years. Of the total respondents, 1167 (58.5%) had a university degree or higher, 1630 (81.7%) were employed, 877 (43.9%) were married, and 36 (1.8 %) had a diagnosis of COVID-19.

Other sample characteristics are reported in Table 1 .

According to the screening assessment by the DSM-5 self-rated level 1 crosscutting symptom measure, a total of 1634 (81.9%) endorsed symptoms of anxiety, (Table 2 ).

The present study investigated the occurrence of mental health problems in the Brazilian general population during the ongoing COVID-19 pandemic. We also assessed factors associated with mental health problems in order to further understand the phenomena and identify higher risk individuals. A remarkably high prevalence of psychiatric symptoms was observed in our sample. More than three-quarters of the subjects endorsed anxiety with moderate-to-severe symptoms, approximately twothirds had symptoms of depression with moderate-to-severe symptoms, and one-third exhibited symptoms of post-traumatic stress. Among the determinants of mental health outcomes, female gender, younger age, lower educational level, low income and J o u r n a l P r e -p r o o f longer period of social distancing were strongly associated with anxiety, depression, and PTSD levels. Brazil is the country with the second highest number of COVID-19 cases in the world after the USA and, as far as we aware, this is the first report about mental health in the Brazilian general population during the outbreak of COVID-19.

The high prevalence of psychiatric symptoms present in our sample indicates that the mental health impact of the pandemic should be considered a public health crisis. The prevalence of anxiety and depression in our sample was much higher than the results from other countries (Xiong et al., 2020) and the Chinese studies, which showed about 30% of their responders experienced anxiety and depressive symptoms Wang et al., 2020) . However, the prevalence of stress in our study was close to that found in the work of Shi. et. al., who reported 24 .4% with acute stress, but higher than in the study of Tee at. al., who reported 16.8% with moderate to severe stress (Tee et al., 2020) , and lower than in the study of Wang et. al., who reported moderate/severe psychological stress in 53.8% of respondents . These discrepancies in terms of prevalence of anxiety and depression may be explained, to some extent, by the socioeconomic and cultural differences between the samples. For instance, approximately 36% of our sample reported an income up to $ 569, while in the Shi's study 77% of their responders reported an income greater than $ 700. Impact of income inequality on mental health status has been suggested in a meta-analysis involving middle low income countries (Ribeiro et al., 2017) .

Another key finding of the present study was the strong association between lower educational level and susceptibility for symptoms of depression, anxiety, and stress. In this regard, a recent study conducted in five different countries in Latin America found that more highly educated neighborhoods were associated with lower odds of internalizing and externalizing disorders (Sampson et al., 2019) . Taken together, the economic and educational disparities and characteristics of our sample, in J o u r n a l P r e -p r o o f addition to the COVID-19 pandemic, may have triggered a burden of poor mental health outcomes in Brazil.

In our sample, young people were more susceptible to depression, anxiety, and stress caused by the COVID-19 pandemic. An adverse environment plays a critical role on mental health at a young age, as showed by increased rates of suicide in young people in Brazil caused by unemployment and social inequality (Jaen-Varas et al., 2019) . It is possible that pre-pandemic distress, such as educational, professional, social, or romantic difficulties typically experienced by young adults, compounded by lifestyle disruptions and feelings hopelessness during the pandemic (Shanahan et al., 2020) , may have contributed to the negative impact on mental health in this subgroup of the sample. Also, older age may be protective because adaptive mechanisms, developed to deal with previous crises, can be used to manage the stress associated with the current pandemic.

Finally, a negative impact of social distancing on mental health was also found, which corroborates a previous report from during the COVID-19 pandemic in China Wang et al., 2020) . Social support is a strong protective factor against mental health problems and has been suggested as a valid coping strategy in this pandemic (Brooks et al.,2020) . In Brazil, the social distancing period has lasted more than 4 months, which may explain, in part, the higher levels of stress and psychiatric symptoms observed in the current study. Furthermore, the longer duration of social distancing and social isolation practices seem to have deleterious effects, in particular, on individuals with psychiatric disorders. In this sense, 40% of our responders had a self-reported history of psychiatric illness which was strongly associated with the severity of current levels of stress, anxiety, and depression. These results are not surprising considering that subjects with a previous history of psychiatric illness are more susceptible to a high risk of recurrence (Batelaan et al., 2017; Rush et al., 2012) , and new episodes may be triggered by stressors.

To the best of our knowledge study, this is the first study to report data on mental health status among the Brazilian general population during the ongoing COVID-19 pandemic. Interpretation of our results should consider some limitations of the study. First, we used an online survey with a convenience sample method, what may not be representative sample of the total Brazilian general population. Second, all outcomes were self-reported instead of evaluated by a clinician. Beyond the associated factors explored in this study, aspects related to the economic impact of the pandemic (e.g., job loss, reduction of economic income), or even fear of infection and death in relatives or friends, may have influenced the increased levels of anxiety or depression (Xiong et al., 2020) . Third, the absence of a pre-pandemic comparison group does not allow us to estimate how much did the pandemic resulted in an increase in the prevalence of psychiatric symptoms compared to the usual prevalence of these symptoms in the Brazilian population. Finally, this is a cross-sectional study and did not provide causal evidence of risk factors and mental health outcomes found in our study.

In conclusion, we found a considerable prevalence of mental health problems, in particular, symptoms of depression, anxiety and stress in a sample of the Brazilian general population during the COVID-19 pandemic. Despite the limitations of the convenience method and the cross-sectional study design, the large sample size allowed us to identify factors associated with a higher severity of psychiatric symptoms.

The levels of psychiatric symptoms observed in our sample suggest that Brazilian health systems and individual clinicians must be prepared to offer and implement specific interventions such as cognitive behavior therapy and mindfulness based therapy in order to treat psychiatric issues. According to our results, these interventions should focus particularly on those with a previous psychiatric diagnosis, lower socio-educational level, younger age and women.

J o u r n a l P r e -p r o o f Data are the percentage of normal/mild and moderate/severe symptoms. Normal/mild is a T-Score up to 55. Moderate/severe is a T-Score >55. Symptoms of PTSD when IES-R score higher than 5.6.

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