Psychiatric symptoms and behavioral adjustment during the COVID-19 pandemic: evidence from two population-representative cohorts

The COVID-19 pandemic has imposed a significant global burden, impacting economies and necessitating lockdowns, quarantines, and social distancing measures. These restrictions limit social interaction and affect personal mobility, relationships, and work/education, mirroring functional impairments in anxiety and depression. This suggests a substantial mental health toll. Governments and organizations have recommended strategies to mitigate this, focusing on maintaining positive routines and creating new meaningful activities to foster psychological resilience. Studies show that maintaining daily routines is crucial in coping with trauma and chronic stress, with successful routine maintenance correlating with reduced psychological distress after disasters. This study aimed to quantify the population prevalence of anxiety and depression during the unfolding pandemic and assess the association between clinically significant symptoms and various daily routines in two population-representative samples in Hong Kong. The study considered disruptions to existing routines (primary: healthy eating, sleep; secondary: socializing, leisure) and the adoption of novel preventive routines (mask-wearing, handwashing, social distancing). It was hypothesized that disruptions to primary and secondary routines, and the absence of new preventive routines, would increase the odds of anxiety and depression.

Existing literature highlights the significant mental health impact of disruptions to daily routines during and after major crises. Studies on survivors of natural disasters and conflict-affected migrants show a strong correlation between routine disruption and increased levels of psychiatric symptoms and psychological distress. A model suggests that psychological resilience during trauma is largely determined by the regularity of daily routines. Previous research on the impact of novel preventive measures like enhanced hygiene practices suggests a potential inverse association with psychiatric symptoms. This study builds upon these findings by investigating the mental health consequences of the COVID-19 pandemic, focusing on a population representative sample and considering the effects of different types of daily routines.

Following ethical approval, two telephone surveys were conducted in Hong Kong between February 25th - March 19th, 2020 (survey 1, low infection) and April 15th - May 1st, 2020 (survey 2, high infection). Random digit dialing targeted 6029 residents (4021 in survey 1, 2008 in survey 2) using a dual-frame approach incorporating landline and mobile numbers. A computer-assisted telephone interview (CATI) system ensured data quality. Response rates were 36.5% (survey 1) and 33.8% (survey 2). Data were weighted by gender, age, and education level to match 2019 census data. Missing data (<1%) was imputed using a multivariate imputation model. The GAD-7 and PHQ-9 were used to assess anxiety and depression, respectively. Disruptions to primary (healthy eating, sleep, household chores) and secondary (socializing, leisure, exercising, work/study) routines were measured using 11-point scales. Novel preventive routines (mask-wearing, handwashing, social distancing etc.) were assessed using dichotomous variables. Mann–Whitney U tests examined sociodemographic differences between groups with and without anxiety/depression. Multivariable logistic regression models assessed the independent association of correlates with anxiety and depression.

The two samples were demographically representative of the Hong Kong population. In survey 1, anxiety prevalence was 14.9% (95% CI = 13.8%–16.0%) and depression prevalence was 19.6% (95% CI 18.4–20.9%). In survey 2, anxiety prevalence was 14.0% (95% CI 12.5%–15.5%) and depression prevalence was 15.3% (95% CI 13.7%–16.9%). Comorbid anxiety and depression were 10.6% (survey 1) and 10.1% (survey 2). Daily rates of clinically significant anxiety showed a U-shaped trend in survey 1 and an irregular pattern in survey 2; depression showed a decreasing trend in survey 1 and an irregular pattern in survey 2. High disruptions to daily routines were significantly associated with increased odds of anxiety and depression in both surveys. The absence of novel preventive routines was associated with reduced odds of anxiety and increased odds of depression in survey 1. Lower socioeconomic status (lower education, unemployment, lack of savings) consistently correlated with increased odds of anxiety and/or depression.

This large-scale study provides valuable insights into the mental health impact of COVID-19 in Hong Kong. The high prevalence of anxiety and depression, exceeding rates observed during previous crises, underscores the significant mental health burden of the pandemic. The strong association between disrupted routines and increased psychiatric symptoms highlights the importance of maintaining daily structure and engagement in meaningful activities for mental well-being. The differing associations between novel preventive routines and mental health outcomes across the two survey periods suggest a complex interplay between protective behaviors and mental health, potentially influenced by the evolving pandemic context and associated stress levels. The consistent association between lower socioeconomic status and increased mental health challenges highlights existing inequalities exacerbated by the pandemic.

This study demonstrates a substantial mental health burden associated with the COVID-19 pandemic in Hong Kong, with high prevalence rates of anxiety and depression linked to disrupted daily routines and socioeconomic factors. Maintaining regular routines and adopting protective behaviors are crucial for mitigating this burden. Further research should explore culturally tailored interventions to support mental health during and after public health crises, focusing on vulnerable populations.

The cross-sectional design limits causal inferences. Self-reported data may be subject to recall bias. The focus on Hong Kong Chinese may limit the generalizability of findings to other populations. The response rates, while acceptable, may introduce non-response bias. Future studies could benefit from longitudinal designs and multi-method approaches to enhance the robustness of findings.