On 24 March 2020, the UK introduced a range of ‘lockdown’ restrictions intended to slow the progression of the COVID-19 outbreak. Emerging evidence indicates that the COVID-19 pandemic is associated with adverse mental health outcomes for healthcare workers in China.Reference Lai, Wang, Cai, Hu and Wei1 Specifically, being female and having an intermediate level of seniority were associated with experiencing severe depression, anxiety and distress. A study conducted with the general population in Italy indicated that COVID-19-related stressful life events were associated with increased odds of post-traumatic stress, depression, anxiety, insomnia, perceived stress and adjustment disorder symptoms.Reference Rossi, Socci, Talevi, Mensi, Niolu and Pacitti2 There is, however, limited data relating to the potential impact of the COVID-19 pandemic on levels of well-being and quality of life (QoL). The capability approach,Reference Nussbaum3 which focuses specifically on the extent to which people have the freedom to engage in valued forms of being and doing, provides a potentially important framework for understanding the impact of the COVID-19 pandemic and the associated lockdown. The lockdown restrictions associated with the pandemic have posed an inherent risk of isolation and a reduction in social connectedness. Research has highlighted that social connections can have positive effects on health and well-being.Reference Jetten, Haslam, Haslam, Dingle and Jones4 The current study, which is part of a programme of research aimed at tracking the impact of the COVID-19 outbreak, investigated whether mental health, well-being and QoL outcomes in UK adults are associated with experiencing symptoms of COVID-19, being in a group vulnerable to COVID-19 (the question read ‘I am classified as being in a vulnerable group in terms of COVID-19 (aged 70 or above, heart disease, lung disease, pregnant, etc)’), being categorised as an ‘essential worker’, experiencing COVID-19-related isolation and local community interactions. Further, the study explored if participants' level of social support was associated with mental health and well-being outcomes.
Method
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. All procedures involving human participants were approved by the Central University Research Ethics Committees, University of Liverpool (reference 7633). Written informed consent was obtained from all participants.
A cross-sectional design was used. A convenience sample recruited via social media forums (Twitter, Facebook, Reddit) completed an online survey. Data was collected over 2 weeks in the initial lockdown period (31 March to 13 April 2020). To be eligible, people had to be adults (≥18 years), speak English and be living in the UK at the time of the COVID-19 outbreak.
The survey included demographic questions; COVID-19-related questions; the Hospital Anxiety and Depression ScaleReference Zigmond and Snaith5 (HADS; higher scores on the subscales indicate higher levels of depression and anxiety symptoms); the World Health Organization (Five) Well-Being Index (WHO-5),6 a measure of well-being (higher scores indicate higher levels of well-being); the Oxford Capabilities Questionnaire for Mental Health (OXCAP-MH),Reference Simon, Anand, Gray, Rugkasa, Yeeles and Burns7 a measure of QoL (higher scores indicate higher levels of QoL) and the Multidimensional Scale of Perceived Social SupportReference Zimet, Dahlem, Zimet and Farley8 (higher scores indicate higher levels of perceived social support).
A total of 600 participants (74% female, mean age 36.75 years, s.d. 13.44, range 18–76 years) completed at a minimum the demographic and COVID-19-related questions. Participants were mainly White (93.6%) and employed (65%). Around a quarter of participants (26.3%) self-reported currently receiving treatment for mental disorders, including mood disorders (18%) and neurotic, stress-related and somatoform disorders (14.3%). No participants had been diagnosed with COVID-19.
Results
The mean scores on the HADS Anxiety subscale (mean 10.23, s.d. 4.98) and HADS Depression subscale (mean 7.57, s.d. 4.39) exceeded the normal range (i.e. scores of 0–7). The mean scores on the WHO-5 and OXCAP-MH were 10.43 (s.d. 5.40) and 69.45 (s.d. 11.91), respectively. Female participants reported significantly higher levels of anxiety symptoms (t(195.73) = −2.21, P = 0.028) than males (female mean 10.51, s.d. 4.85; male mean 9.33, s.d. 5.29). There were no significant differences in the level of depression symptoms, well-being and QoL between males and females.
Being in a vulnerable group (12.5%) or experiencing symptoms of COVID-19 (11.7%) were not associated with significant differences in mental health and well-being outcomes (see Table 1). Participants who self-isolated before lockdown owing to symptoms of COVID-19 (11.8%) had higher levels of anxiety (t(584) = 2.77, P = 0.006) and depression (t(550) = 2.83, P = 0.005) symptoms, and lower levels of well-being (t(534) = −2.29, P = 0.022) and QoL (t(466)= −3.56, P < 0.001), relative to those who did not. Participants who felt more isolated than usual during lockdown (69%) had higher levels of anxiety (t(513) = −5.95, P < 0.001) and depression (t(250.86)= −7.77, P < 0.001) symptoms, and lower levels of wellbeing (t(191.84) = 6.18, P < 0.001) and QoL (t(441) = 4.16, P < 0.001).
Between-group analyses for HADS, OXCAP-MH and WHO-5
HADS, Hospital Anxiety and Depression Scale; OXCAP-MH, Oxford Capabilities Questionnaire for Mental Health; WHO-5, World Health Organization (Five) Well-Being Index.
*P < 0.05; **P < 0.01; ***P < 0.001.
Participants who were essential workers (32%) had significantly lower levels of depression symptoms (t(400.76) = −2.18, P = 0.030). Participants who agreed that the COVID-19 outbreak was threatening their livelihood (46.0%) had higher levels of depression symptoms (t(544) = −2.55, P = 0.011) and lower QoL (t(461) = 2.73, P = 0.007).
Participants who agreed that people's kindness toward others in their local area had increased since the COVID-19 outbreak (68.8%) had lower levels of depression symptoms (t(551) = 2.25, P = 0.025), and higher QoL (t(467) = −4.56, P < 0.001) and well-being (t(535) = −2.85, P = 0.005). Similarly, participants who agreed that they had felt more connected to the members of their local community since the COVID-19 outbreak (40.0%) had lower levels of depression symptoms (t(552) = 2.11, P = 0.035), and higher QoL (t(467) = −3.87, P < 0.001) and well-being (t(536) = −2.83, P = 0.005).
The level of perceived social support had significant negative correlations with levels of depression (r = −0.33, P < 0.001) and anxiety (r = −0.17, P < 0.001) symptoms, and significant positive correlations with QoL (r = 0.52, P < 0.001) and well-being (r = 0.29, P < 0.001).
Discussion
This study sought to investigate the impact of the COVID-19 outbreak on the mental health and well-being of a convenience sample of UK adults. The levels of anxiety and depression symptoms for the sample were markedly higher than normative data derived for the UK adult population's levels of anxiety (females 6.78, s.d. 4.23; males 5.51, s.d. 4.04) and depression (females 4.12, s.d. 3.78; males 3.83, s.d. 3.74)Reference Breeman, Cotton, Fielding and Jones9 symptoms.
Higher levels of depression symptoms were associated with participants having to self-isolate before lockdown owing to symptoms of COVID-19, feeling more isolated than usual during lockdown or agreeing that the COVID-19 pandemic was threatening their livelihood. On the other hand, agreeing that people's kindness toward others had increased, agreeing that they felt more connected to people in the local community, and working in an essential job were associated with significantly lower levels of depression symptoms. Notably, the mean depression score for the essential workers (mean 7.01, s.d. 4.04) remained at the upper limit of the normal range. These findings are open to interpretation, but it may be that the importance of their work and/or public acknowledgment of their efforts buffered against higher levels of depression symptoms.
The significant findings relating to isolation (self-isolating before lockdown or feeling more isolated during lockdown) and levels of perceived social support highlight the importance of exploring innovative ways to maintain connection and social support during periods of lockdown and beyond. These findings, although correlational in nature, are consistent with the thesis that psychological resources associated with social connectedness can serve as a ‘social cure’ for mental health difficulties.Reference Saeri, Cruwys, Barlow, Stronge and Sibley10
Comparatively high levels of both well-being and QoL were associated with participants agreeing that levels of kindness in the local area had increased, and that they felt more connected to others in the local community during the COVID-19 pandemic. QoL, but not well-being, was comparatively lower in participants who indicated that their livelihood was threatened by the COVID-19 pandemic. We propose that the OXCAP-MH, as a multidimensional measure of QoL that incorporates a focus on a range of factors including non-health issues and welfare inequalities, is a valuable measure for assessing how COVID-19 and related restrictions are potentially affecting people.
There were a number of important limitations associated with the current study. The convenience sample relied on people who had access to online social media forums. Consistent with other studies that have used social media for recruitment,Reference Whitaker, Stevelink and Fear11 males and Black, Asian and minority ethnic community members were comparatively under-represented in the sample. The cross-sectional nature of the analyses limits the conclusions that can be drawn. However, forthcoming academic papers from the authors will track the impact of the COVID-19 pandemic and lockdown restrictions on mental health and well-being over time.
The study highlights that although there was no association between personal experience of COVID-19 symptoms and being part of a group vulnerable to the effects of COVID-19, and mental health and well-being, factors related to isolation and COVID-19-related livelihood concerns were in fact associated with poorer mental health and well-being. On the other hand, perceiving increased kindness and connectedness in local areas were associated with better mental health and well-being outcomes. Further research aimed at mitigating the mental health and well-being effects of public health emergencies is required.
Data availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Author contributions
R.G.W. formulated the research questions, designed the study, conducted the study, analysed the data and wrote the article. C.V.D.B. formulated the research questions, designed the study, conducted the study, analysed the data and wrote the article.
Declaration of interest
None.
ICMJE forms are in the supplementary material, available online at https://doi.org/10.1192/bjo.2020.79.
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