Psychological Effects and Associated Factors of COVID-19 in a Mexican Sample

Objectives: The coronavirus disease 2019 (COVID 19) is a new viral zoonosis of global concern that could cause psychological sequelae. We examined the levels of psychological distress, anxiety, depression, and stress during the COVID-19 outbreak in a Mexican sample. Methods: An online survey was applied that collected information on demographic and financial status data, physical status, contact history, knowledge, concerns, and precautionary measures concerning COVID-19. Impact of Event Scale-Revised and Depression, Anxiety, and Stress Scale were included. Results: A total of 50.3% of respondents rated psychological distress as moderate-severe; 15.7% reported moderate-severe depressive symptoms; 22.6% reported moderate-severe anxiety symptoms; and 19.8% reported moderate-severe stress levels. Female gender, older age, divorced status, lack of confidence related to security of the test, lower satisfaction of health information concerning COVID-19, history of direct or indirect contact with a COVID-19 confirmed case, live with just 1 other person, and spent >9 h/d at home were associated with greater psychological distress and/or higher levels of stress, anxiety, and depression. By contrast, precautionary measures, such as hand hygiene and wearing masks, were associated with lower levels of psychological distress, depression, anxiety, and stress. Conclusions: COVID-19 outbreak results in considerable psychological effects among the Mexican sample.

C oronavirus disease 2019 (COVID-19) originated in the city of Wuhan, China, on December 31, 2019. Since its discovery, a rapid community, regional, and international spread has occurred with exponential growth in cases and deaths. 1 The COVID-19 outbreak was confirmed to have reached Mexico on February 28, and on March 30, the Mexico government declared a national health emergency. 2 In the face of a health crisis, not seen in several years, response efforts by the government in coordination with the Secretaría de Salud (Ministry of Health) of Mexico have been swift, implementing a series of preventions, actions, and control infections in the country, including extension of school vacation period, home office, restriction of massive events, suspension of "nonessential activities" in all economic sectors, and the recommendation of home confinement for the general population. 3 Some negative implications that COVID-19 has had in Mexico include the generation of panic buying and shoplifting, which in turn has led to the eventual shortage of antibacterial hand gel and face masks, 4 a fall in the price of fuel, 5 and the temporary or definitive closure of companies. 6 In fact, in the past month, 346,878 formal jobs were lost in Mexico between March 13 and April 6. 7 COVID-19 not only threatens people's physical health, but also could affect people's mental health, as many theories indicate. For example, according to Behavioral Immune System theory, 8 people show emotions, such as aversion and anxiety, for selfprotection. 9,10 Moreover, stress theory 11 and perceived risk theory 12 mention that public health emergencies trigger negative emotions, which may reduce the immune function of people and destroy the balance of their normal physiological mechanisms. 13 In support, previous studies have shown the immediate psychological sequelae of a pandemic, as occurred with severe acute respiratory syndrome (SARS) and H1N1, include stress, poor sleep, depressed mood, weepiness, nightmares, and poor concentration. 14 Furthermore, it has also been shown that people experience fear of falling sick or dying themselves, feelings of helplessness, irrational nervousness, loneliness, and stigma. 15,16 Also, it has been identified that certain groups are more vulnerable to high psychological distress during a pandemic. Taylor et al. reported that, during an outbreak of equine influenza, younger people, those with no formal educational qualifications, and those with financial dependence on an industry facing a crisis are significantly predisposed to high psychological distress. Finally, the authors also identified that those with 1 child had a 1.2 times higher risk of high psychological distress than those with no children. 17 For their part, during pandemic influenza, Jacobs et al. found that individuals with poor self-rated health reported greater risk perception and concern for self and others than individuals with good self-rated health. 18 Finally, di Giuseppe et al. reported that people with lower socioeconomic status and lower education showed significantly higher risk perception during avian influenza. 19 Therefore, it is essential to understand the potential psychological effects caused by COVID-19 in a timely manner. Based on our understanding, there is no information on the psychological distress and mental health of Mexican populations concerning COVID-19. This is especially pertinent with the uncertainty surrounding an outbreak of such unparalleled magnitude in our country. Therefore, this study aims to examine the levels of psychological distress (anxiety, depression, and stress) and identify risk factors contributing to worse outcome during the COVID-19 outbreak in a Mexican sample. We hypothesized that most of the respondents will show severe psychological distress and moderate depressive, anxiety, and stress levels caused by COVID-19. In addition, age, gender, and financial status will be factors contributing to worse outcomes.

Participants and Procedure
We carried out a cross-sectional study design. As the Mexican Government recommended home confinement for the general population, an anonymous online questionnaire in Spanish was applied through an online survey platform ("Google Forms", Google Inc., CA). The online survey was first disseminated to university students, and they were encouraged to pass it on to others. A snowball sampling strategy, focused on recruiting the general public living in the whole country during the epidemic of COVID-19, was used. This study was conducted in compliance with the Norma Oficial Mexicana-012-SSA3-2012, Declaration of Helsinki and the Ethics Committee of Universidad José Martí (Approval number 2020-3). Informed consent was obtained from all participants included in the study. Data collection was carried out from March 30 to April 5, that is, immediately after a national health emergency was declared in Mexico.

Survey
We reviewed a previous survey on the psychological distress of COVID-19 performed in China. 20 In addition, we included questions related to employment status during the COVID-19 outbreak. The questionnaire consisted of 70 items (about the past 14 days) that covered 8 areas: demographic data, financial status, physical health, contact history, knowledge and concerns, precautionary measures, psychological distress, and mental health status (more details see Appendix 1, online only).

Statistical Analysis
Descriptive statistics was used for categorical variables, such as sociodemographic characteristics, financial status, physical status, contact history, knowledge and concerns, and precautionary measures. Univariate generalized linear with a main effects model (linear regression) was used to measure the associations between sociodemographic characteristics, financial status, physical status, contact history, knowledge and concerns, and precautionary measures with regard the total IES-R score and DASS-21 subscales scores. Associations are presented using beta coefficients, confidence intervals, and P-values. The significance level was set at 0.05. Analyses were performed in IBM SPSS Statistics (version 25.0).

RESULTS
A total of 1105 persons from 32 states in Mexico were included in the study (more details see Appendix 2, online only) from a convenience sample of 1109 respondents (response rate = 99.63). Sociodemographic characteristics of the final sample of respondents are presented in Table 1. The majority of respondents were female (62.1%), aged 18 to 28 y (68.7%) (SD = 10.46), single (71.1%), with a household size of >3 people (51.6%), without children (67.4%), and well educated (71.2% ≥ college degree).

Psychological Distress and Mental Health
The psychological distress of COVID-19 outbreak, measured using the IES-R scale, revealed a sample mean score of 26.07 (SD = 19.33). Of the total respondents, 33% reported minimal psychological distress, 16.7% rated mild psychological distress, and 50.3% reported moderate or severe psychological distress. About the DASS 21 scale, who assessed mental health, revealed a sample mean score of 13.38 (SD = 4.51). Results showed that 15.7% reported moderate to severe depressive symptoms, 22.6% of respondents reported moderate to severe anxiety symptoms, and 19.8% reported moderate to severe stress levels.

Sociodemographic Characteristics, Psychological Distress, and Mental Health
The results of the associations of psychological distress and mental health according to the sociodemographic variables are shown in Table 2.

Marital Status
Divorced status was significantly associated with higher scores in DASS-21 subscale depression (B = 0.630; 95% CI = 0.168 to 1.093). Marital status was not associated with IES-R score.

Financial Status, Psychological Distress, and Mental Health
Employed (52.4%) and student (38.8%) status were more frequent for respondents. The most common monthly income was 0-4000 MXN. Most of the employees did not show risk for job loss (56.6%), reduction in working days (58.8%), or reduction in monthly income (52.0%). The financial status was not associated with DASS-21 and IES-R subscale scores (see Table 3).    Table 4).  Table 5). Satisfaction level about the amount of health information available about COVID-19 was significantly associated with higher scores in DASS-21 depression subscale. No associations were found between the satisfaction about the amount health information and IES-R scores. Finally, the level of satisfaction about amount information that the government provided regarding new cases and treatments of COVID-19 was significantly associated both higher scores in DASS-21 (anxiety and stress subscale) and IES-R scale. Social network, as the main source of information about COVID-19, was significantly associated with a higher IES-R scale score (B = 3.419; 95% CI = 0.613 to 6.226) (see Table 6).

Precautionary Measures, Psychological Distress, and Mental Health
The main precautionary measures about COVID-19 were hand washing behavior (35.74%), home confinement Regarding assessment with the IES-R, respondents that stay at home >9 h showed a significant association with higher scores in the scale IES-R and the DASS-2 depression subscale (see Table 7).

Psychological Effects and Associated Factors of COVID-19 in a Mexican Sample
Disaster Medicine and Public Health Preparedness anxiety symptoms; and 19.8% reported moderate to severe stress levels. The prevalence of moderate or severe psychological distress as measured by IES-R was higher than the prevalence of depression, anxiety, and stress as measured by the DASS-21. The differences in the results obtained between IES-R and DASS-21 may be due to the fact that the IES-R assesses psychological distress after a specific event. Therefore, respondents might refer the COVID-19 outbreak as the event, while the DASS-21 did not specify any such event, as previously reported. 20 According to similar epidemics and pandemics, in such cases, serious concerns, such as fear of death can arise, and feelings of loneliness and anger can develop among people who are quarantined. 26 In addition, people who are quarantined lose face-to-face connections and traditional social interventions, and this is a stressful phenomenon. 27 Therefore, at these points, it was not surprising to find that the Mexican sample showed severe psychological distress during the COVID-19 outbreak, similarly with the findings originating from China, 20,28 Canada, 29 Iran, 27 Japan, 30 and Singapore. 31 In support, it is recognized that widespread outbreaks of infectious diseases, such as SARS, 32 H1N1, 33 and actually, COVID-19, are associated with psychological distress and symptoms of mental illness. 34 Both psychologists, psychiatrists, and the health care system at large should be aware of these manifestations to subsequently implement early psychological interventions according the needs of specific populations.
Our findings suggest that females suffered greater psychological distress of the outbreak as well as higher levels of stress, anxiety, and depression. This finding corresponds to previous studies which found that women were at higher risk of depression, 35,36 anxiety, 37 and stress. 38 It is likely that genetic, biological, chemical, hormonal, environmental, psychological, and social factors all intersect to contribute to mental disorders in women. 39 In addition, we found that with older age, participants showed greater stress and had a greater psychological distress of COVID-19 outbreak. Young, middle-aged, and older adults may have different levels of exposure to school-related, work-related, and health-related stressors because of their life stages and associated life events. 40 In addition, the Mexico government has shut down schools at all levels indefinitely. Currently, teachers are using online platforms to deliver lectures or other teaching activities. However, the uncertainty and potential negative distress on academic progression could have an adverse effect on the mental health of young people.
We found that divorced status had a greater likelihood of depression during the epidemic; in support, prior findings showing that the end of marriage through divorce is associated with a significant increase in the probability of a future depressive episode. 41 Participants who live with 1 other person exhibited greater anxiety and greater psychological distress of the COVID-19 outbreak. This finding corresponds to  previously extensive epidemiological studies which found that family size predicts anxiety. 42 On the other hand, it is necessary that the health authorities identify the immediate psychological needs of the general population presenting with physical symptoms during the epidemic. Our results revealed that the Mexican sample, which presented specific symptoms of COVID-19, experienced greater psychological distress on the outbreak and higher levels of stress, anxiety, and depression. Health professionals should take the opportunity to provide resources for psychological support and interventions for those who present with the above symptoms, especially during clinical consultations. Moreover, such interventions should also be guaranteed for infected individuals and their caregivers. 20 Taking a family history is essential, and health professionals should enquire about the level of concern for other family members of contracting COVID-19, as these concerns are associated with altered mental status. In support, our results showed respondents had been in direct or indirect contact exhibited higher levels of anxiety, stress, and depression.
The goal of communication before and during a pandemic is to provide and exchange relevant information with the public, partners, and stakeholders to allow them to make wellinformed decisions and take appropriate actions to protect health and reduce the distress of rumors. 43 In our study, lack of confidence in the COVID-19 test security and lower satisfaction with the health information received were associated with higher psychological distress of the outbreak and higher levels of stress, anxiety, and depression. Therefore, it is crucial to provide clear health information, with comprehensible messages and based on evidence to avoid adverse psychological reactions. 44 A major adverse consequence of the COVID-19 pandemic is likely to be increased social isolation and loneliness, which are strongly associated with anxiety, depression, self-harm, and suicide attempts across the lifespan. 45 In our study, the majority of the participants that were homebound for >9 h/d during the epidemic suffered greater psychological distress from the outbreak as well as higher levels of depression. Under these conditions, the content of psychological interventions needs to be modified to suit the needs of the general population during the epidemic. Psychologists should produce and disseminate information materials on the psychological consequences of the quarantine and toll-free numbers should be activated to support all those who are confronted with psychological distress. 46 For example, cognitive behavior therapy could be delivered online or by means of telephone to counteract depression in the home environment. For this reason, fine tuning effective psychological interventions is a future need, given that, after the public health emergency, a psychological distress emergency seems on the horizon.
Finally, our findings showed that specific precautionary measures as hand hygiene and wearing masks were associated with Psychological Effects and Associated Factors of COVID-19 in a Mexican Sample lower levels of psychological distress, depression, anxiety, and stress. Our finding is similar to a previous study, which suggests that the precautionary measures adopted to prevent the spread of COVID-19 could have had protective psychological effects during the early stage of the epidemic. 20 This study has several limitations. First, due the time-sensitivity of the COVID-19 outbreak, we used the snowball sampling strategy; this strategy was not based on a random selection of the sample, and the study population did not reflect the actual pattern of the general population. Second, the sampling was carried out by students, leading to selection bias. Therefore, our conclusion was less generalizable to the entire population, particularly less-educated people. Last, the number of respondents with contact history and who had sought medical consultations was very small. As a result, our findings could not be generalized to confirmed or suspected cases of COVID-19.
Notwithstanding the above limitations, this study provides invaluable information on the psychological effects in the Mexican sample, 1 wk after the outbreak of COVID-19 was declared a national health emergency in Mexico. In addition, our results could be used as a historical reference and provide a baseline for evaluating prevention, control, and treatment efforts throughout the remainder of the COVID-19 epidemic.

CONCLUSIONS
Together, the data show that the COVID-19 outbreak results in considerable psychological distress among the Mexican sample examined. Public health officials, infectious diseases physicians, psychiatrists, psychologists, and the health care system at large need to be made aware of this issue.