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

The COVID-19 pandemic, and associated public health measures such as lockdowns, quarantine, and social/physical distancing, have substantially disrupted daily life, including mobility, interpersonal relationships, and occupational/educational roles. Such functional disruptions resemble impairments observed in common mental disorders (anxiety, depression), suggesting a significant mental health burden. Governments and NGOs issued guidance encouraging maintenance of existing positive routines and development of new activities to mitigate psychological impact. A resilience model posits that regularity of daily routines supports psychological resilience during trauma and chronic stress. Prior research shows that sustaining or restoring daily routines after disasters reduces psychological distress, and disruptions to daily experiences among conflict-affected migrants are associated with higher psychiatric symptoms. Building on this, the present study aimed to quantify population prevalences of anxiety and depression as the pandemic unfolded in Hong Kong, and to test whether disruptions to longstanding primary routines (healthy eating, sleep) and secondary routines (socializing, leisure), as well as absence/presence of novel preventive routines (e.g., mask-wearing, hand hygiene, avoiding crowds), were associated with clinically significant anxiety and depression. The authors hypothesized that greater disruptions to primary and secondary routines and lack of adoption of novel preventive routines would relate to increased odds of anxiety and depression.

Guidance from governments and NGOs during COVID-19 emphasized maintaining regular routines and engaging in meaningful activities (household chores, exercise, leisure, socialization through new means) to mitigate mental health impacts. A theoretical model links the regularity of daily routines to resilience under trauma and chronic stress. Empirical evidence indicates that maintaining daily activities after natural disasters aids coping and that restoration/sustainment of pre-disaster life correlates with reduced distress up to six years after the Great East Japan Earthquake. Among conflict-affected migrants, disruptions to various daily experiences associate with higher psychiatric symptoms and general distress. Additionally, during early COVID-19 outbreaks in China, engagement in personal hygiene behaviors (mask-wearing, handwashing, covering mouth when coughing/sneezing) was inversely associated with psychiatric symptoms in convenience samples. These literatures suggest both the protective role of routine regularity and potential benefits of novel preventive behaviors for mental health during pandemics.

Design and setting: Two population-representative telephone surveys of Hong Kong Chinese residents were conducted during distinct pandemic phases: Survey 1 (Feb 25–Mar 19, 2020; low infection/limited intervention; 70 cumulative cases by Feb 24) and Survey 2 (Apr 15–May 1, 2020; high incidence/intensive measures; 871 new cases Mar 15–Apr 14). Ethics approval was obtained from The Education University of Hong Kong. Survey administration used a computer-assisted telephone interview (CATI) system by two professional survey organizations. Sampling and participants: Random digit dialing with a dual-frame (50% landline, 50% mobile) approach produced population-representative samples. Inclusion criteria: Hong Kong Chinese, age ≥15, Cantonese-speaking. For landlines, the household member with the next birthday was selected. Calling protocols included repeated attempts for no answer/busy/not at home. Oral informed consent obtained. Interviews were conducted 2–10 pm on weekdays/weekends. Response rates: Survey 1: 36.5% (cooperation 77.2%, error ±2.2% 95% CI); Survey 2: 33.8% (cooperation 73.5%, error ±3.1% 95% CI). Final weighted sample sizes: n=4021 (Survey 1), n=2008 (Survey 2). Measures:

• Disruptions to daily routines: In Survey 1, one 11-point item (0=no disruptions, 10=high disruptions) each for primary routines (healthy eating, sleep) and secondary routines (socializing, leisure). In Survey 2, additional items captured primary routine (household chores) and secondary routines (exercising/keeping active, work/study). Disruption scores were recoded into low (<1 SD below mean), medium (within 1 SD), and high (>1 SD above mean) for analyses.
• Novel preventive routines: Survey 1 (yes/no): mask-wearing when going out; washing hands often; avoiding people with respiratory symptoms; avoiding going to crowded places; avoiding public transport. Survey 2 added: staying at home as much as possible; using hand sanitizer; disinfecting the house. Behaviors aligned with Centre for Health Protection guidance.
• Anxiety: GAD-7 assessing past-2-week symptoms (0–21). Clinical cutoff ≥10. Internal consistency α=0.93 in both surveys.
• Depression: PHQ-9 (Chinese) assessing past-2-week symptoms (0–27). Clinical cutoff ≥10. Internal consistency α=0.86 (Survey 1) and α=0.85 (Survey 2).
• Demographics: Age, gender, marital status, education, employment, monthly household income, income change, savings. Statistical analysis: Data weighted by gender, age, education to the 2019 Hong Kong census. Weights computed as products of single-factor weights; age/education recoded to census categories. Missing data (<1%) handled via multivariate iterative imputation. Prevalences estimated with 95% CIs. Day-to-day prevalence trends portrayed using nonparametric loess smoothing and mapped to daily confirmed cases. Group differences in sociodemographics by clinical anxiety/depression tested with Mann–Whitney U tests. Multivariable logistic regression models included disruptions to routines, novel preventive routines, and sociodemographics significant in bivariate analyses. Outcomes: clinical anxiety (GAD-7 ≥10) and depression (PHQ-9 ≥10). Results presented as adjusted odds ratios (aOR) with 95% CIs. Analyses conducted in SPSS v26; two-tailed α=0.05.

Sample representativeness: Both samples resembled the Hong Kong population on key demographics. Prevalence: Clinical anxiety was 14.9% (95% CI 13.8%–16.0%) in Survey 1 and 14.0% (95% CI 12.5%–15.5%) in Survey 2. Clinical depression was 19.6% (95% CI 18.4%–20.9%) in Survey 1 and 15.3% (95% CI 13.7%–16.9%) in Survey 2. Comorbid anxiety and depression: 10.6% (95% CI 9.7%–11.6%) in Survey 1; 10.1% (95% CI 8.8%–11.4%) in Survey 2. Day-to-day trends showed a U-shaped pattern for anxiety and a decreasing trend for depression in Survey 1; both were irregular in Survey 2. Routine disruptions and behaviors: 22–24% reported high disruptions to healthy eating and sleep; 28% reported high disruptions to socializing and leisure. In Survey 2, high disruptions were similar for exercising/keeping active (22.8%) and work/study (20.0%). Preventive behaviors were widely adopted: mask-wearing >97%, handwashing >92%; increases from Survey 1 to Survey 2 for avoiding symptomatic people, avoiding crowds, avoiding public transport; in Survey 2, staying at home 90.6%, using hand disinfectants 88.7%, disinfecting house 83.7%. Multivariable associations:

• Survey 1: Higher odds of clinical anxiety were associated with medium/high disruptions to healthy eating, sleep, socializing, and leisure (vs low), reporting avoidance of people with respiratory symptoms, female gender, and income decline. Higher odds of clinical depression were associated with medium/high disruptions to healthy eating, sleep, socializing, and leisure; not avoiding going to crowded places (i.e., absence of this preventive routine); age ≥25 (vs 15–24), female gender, unemployment, and income decline.
• Survey 2: Higher odds of clinical anxiety were associated with medium/high disruptions to healthy eating, sleep, socializing, leisure, and work/study; disinfecting the house; unemployment; and lack of savings. Higher odds of clinical depression were associated with medium/high disruptions to healthy eating, sleep, socializing, leisure, and work/study; lower education (primary/secondary); unemployment; and lack of savings. Overall interpretation: Disruptions to both primary and secondary routines consistently related to increased odds of anxiety and depression across pandemic phases. The absence of certain novel preventive routines (e.g., avoiding crowded places) was associated with higher depression early in the pandemic. Indicators of lower socioeconomic status (lower education, unemployment, income decline, lack of savings) were robust risk factors.

The study addressed whether disruptions to daily routines and adoption of novel preventive behaviors were linked to psychiatric symptoms during COVID-19. Using two large, representative Hong Kong samples at different pandemic phases, the authors found elevated prevalences of anxiety and depression relative to earlier public health/social crises and consistent associations between greater disruptions to primary (sleep, healthy eating) and secondary (socializing, leisure, work/study) routines and higher odds of clinical anxiety and depression. These findings align with resilience models emphasizing the protective role of routine regularity and with disaster literature on the benefits of restoring everyday life. The results also indicate that, in the early phase, not adopting certain preventive behaviors (e.g., avoiding crowded places) related to higher depression, whereas some preventive actions (e.g., avoidance of symptomatic people; disinfecting the house) correlated with greater anxiety, potentially reflecting heightened threat vigilance. Socioeconomic vulnerabilities (lower education, unemployment, income decline, lack of savings) compounded risk for psychiatric symptoms. Together, the findings suggest that promoting the maintenance of core daily routines and supporting feasible preventive behaviors, while addressing socioeconomic stressors, may mitigate mental health burdens during pandemics.

This research provides population-representative evidence from Hong Kong that clinically significant anxiety and depression were common during early COVID-19 phases and were strongly associated with disruptions to primary and secondary daily routines. Adoption (or lack) of certain novel preventive routines had phase-specific associations with psychiatric symptoms, and lower socioeconomic status consistently signaled heightened risk. The study underscores the importance of public health strategies that help individuals sustain regular routines (sleep, diet, activity, social/leisure engagement, work/study structure) alongside appropriate preventive behaviors. Future research should employ longitudinal designs to establish causal pathways between routine disruption and mental health, evaluate targeted interventions to stabilize daily routines under restrictions, and explore mechanisms by which specific preventive behaviors influence psychological outcomes across different pandemic phases and population subgroups.