Editor's evaluation: Investigating the relationship of COVID-19 related stress and media consumption with schizotypy, depression, and anxiety in cross-sectional surveys repeated throughout the pandemic in Germany and the UK

Abstract

Article Figures and data Abstract Editor's evaluation eLife digest Introduction Materials and methods Results Discussion Data availability References Decision letter Author response Article and author information Metrics Abstract Background: Studies report a strong impact of the COVID-19 pandemic and related stressors on the mental well-being of the general population. In this paper, we investigated whether COVID-19 related concerns and social adversity affected schizotypal traits, anxiety, and depression using structural equational modelling. In mediation analyses, we furthermore explored whether these associations were mediated by healthy (sleep and physical exercise) or unhealthy behaviours (drug and alcohol consumption, excessive media use). Methods: We assessed schizotypy, depression, and anxiety as well as healthy and unhealthy behaviours and a wide range of sociodemographic scores using online surveys from residents of Germany and the United Kingdom over 1 year during the COVID-19 pandemic. Four independent samples were collected (April/May 2020: N=781, September/October 2020: N=498, January/February 2021: N=544, May 2021: N=486). The degree of schizotypy was measured using the Schizotypal Personality Questionnaire (SPQ), anxiety, and depression symptoms were surveyed with the Symptom Checklist (SCL-27), and healthy and unhealthy behaviours were assessed with the Coronavirus Health Impact Survey (CRISIS). Structural equation models were used to consider the influence of COVID-19 related concerns and social adversity on depressive and anxiety-related symptoms and schizotypal traits in relation to certain healthy (sleep and exercise) and unhealthy behaviours (alcohol and drug consumption, excessive media use). Results: The results revealed that COVID-19 related life concerns were significantly associated with schizotypy in the September/October 2020 and May 2021 surveys, with anxiety in the September/October 2020, January/February 2021, and May 2021 surveys, and with depressive symptoms in all surveys. Social adversity significantly affected the expression of schizotypal traits and depressive and anxiety symptoms in all four surveys. Importantly, we found that excessive media consumption (>4 hr per day) fully mediated the relationship between COVID-19 related life concerns and schizotypal traits in the January/February 2021 survey. Furthermore, several of the surveys showed that excessive media consumption was associated with increased depressive and anxiety-related symptoms in people burdened by COVID-19 related life. Conclusions: The ongoing uncertainties of the pandemic and the restrictions on social life have a strong impact on mental well-being and especially the expression of schizotypal traits. The negative impact is further boosted by excessive media consumption, which is especially critical for people with high schizotypal traits. Funding: FK received funding from the European Union’s Horizon 2020 (Grant number 754,462). SN received funding from the Cundill Centre for Child and Youth Depression at the Centre for Addiction and Mental Health, Toronto, Canada and the Wellcome Trust Institutional Strategic Support Fund from the University of Cambridge. Editor's evaluation Using online surveys from Germany and the U.K. participants, this study examined the association between COVID-19 and mental health mediated by participants' behaviors. The results indicate that the pandemic was substantially associated with depressive and anxiety symptoms. Furthermore, unhealthy behaviors such as excessive media consumption further exacerbated the negative impact of social isolation due to COVID. https://doi.org/10.7554/eLife.75893.sa0 Decision letter Reviews on Sciety eLife's review process eLife digest The 2020 COVID-19 pandemic, and the measures different governments took to contain it, harmed many people’s mental well-being. The restrictions, combined with pandemic-related uncertainty, caused many individuals to experience increased stress, depression, and anxiety. Many people turned to unhealthy behaviours to cope, including consuming more alcohol or drugs, using media excessively, developing poor sleeping habits, or reducing the amount of exercise they did. Stress, drugs, poor sleep, and uncertainty can increase an individual’s risk of developing psychotic symptoms, including delusions, hallucinations, or difficulty thinking clearly. These symptoms may be temporary or part of a more lasting condition, like schizophrenia. The risk of developing these symptoms increases in people with ‘schizotypal traits’, such as a lack of close relationships, paranoia, or unusual or implausible beliefs. These individuals may be especially vulnerable to the harmful mental health effects of the pandemic. Daimer et al. demonstrated that people who were more worried about their life stability or financial situation during the 2020 COVID-19 pandemic had worse mental well-being than those who felt secure. In the experiments, volunteers completed a series of online mental health questionnaires at four different time points during the pandemic. People who reported feeling lonely, having negative thoughts, or experiencing fewer positive social interactions had more symptoms of mental illness. People who experienced more life disruptions also reported more anxiety or depression symptoms and more schizotypal traits. Daily consumption of at least four hours of digital media exacerbated negative mental health symptoms, and people with more pandemic-related life concerns also spent more time on digital media Daimer et al. suggest that increased media consumption among people with pandemic-related hardships may have increased mental health symptoms and schizotypal traits in these individuals. The survey results suggest that maintaining a healthy lifestyle, including meaningful relationships, is essential to staying mentally healthy during extreme situations like a global pandemic. Protective interventions – such as strengthening social support networks, providing mental health education, or increasing mental healthcare provisions – are essential to prevent poor mental health outcomes during future crises. Introduction Starting in Wuhan, China, the novel highly infectious severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, COVID-19) spread rapidly around the world in the first months of 2020 and was declared as a pandemic by the WHO on 13 March 2020. At the time of writing, more than 258 million people worldwide had contracted the illness, and more than 5.2 million died with or from COVID-19 (Daly and Robinson, 2021; JHU, 2021). Even after successful vaccination programmes were implemented in many countries (ECDE, 2021), the uncertainties and restrictions still impacted many areas of daily life. In many countries, measures such as ‘lockdown’ or ‘social distancing’ introduced by governments early on Cohen and Kupferschmidt, 2020 are now procedures regularly and flexibly applied to combat the pandemic. Many educational institutions, childcare facilities, bars, and restaurants have been closed over long periods during the past 1.5 years, and cultural or sporting events still being cancelled or highly restricted. Governments in different countries differed in their approaches to tackling the pandemic (Plümper and Neumayer, 2020). For example, at the start of the pandemic, the United Kingdom (UK) imposed a nationwide lockdown a few days after Germany, which may have led to higher case and mortality rates. However, the UK started vaccinating earlier and faster than Germany, which allowed earlier relaxations of restrictions (McRobbie et al., 2020; Pritchard et al., 2021). Due to delays in vaccine purchases, significantly less vaccines were available in EU countries, which contributed to fewer vaccinations compared to the UK (Sasse, 2021). Figure 1 shows the number of cases, deaths, and vaccinations per day averaged over the week until June 2021. Figure 1 Download asset Open asset Progression of COVID-19 cases, deaths, and vaccine rate (first dose) in comparison between Germany and the UK from January 2020 to June 2021. Germany: 1. State-wise lockdown (LD) on 16 March 2020; UK: 1. National LD on 23 March 2020. Numbers of vaccinations averaged over the week. Data (cases and deaths) taken from the 2019 Novel CoronaVirus CoViD (2019-nCoV) data repository by Johns Hopkins University Center for Systems Science and Engineering (JHU CSSE). Data for UK vaccination rate taken from GOV.UK Coronavirus in the UK (https://coronavirus.data.gov.uk/details/vaccinations) and for the German vaccination rate from Impfdashboard (https://impfdashboard.de/daten). The grey bars mark the time sections of data collection in the present study. Early on, experts expressed concern that the fear of contracting the infection with SARS-CoV-2 as well as pandemic related stressors such as social restrictions, financial preoccupations, task overload, inadequate information, frustration, and boredom posed a risk for mental health, and may be reflected in particular in depressive and anxiety-related symptoms (Amsalem et al., 2021; Brooks et al., 2020). Social distancing measures in particular represent a macro-stressor affecting the majority of people in an unprecedented manner (Ahrens et al., 2021). Different studies indeed showed that severe restrictions of social contacts as well as the fear of the virus or the impact on living conditions had a measurable impact on the mental health of general populations all over the world (Bu et al., 2020; Smith et al., 2020; Wang et al., 2020b). During the first lockdown, increased levels of perceived stress and mental distress, COVID-19 related fear, general anxiety and depression, and a general decline in mental well-being were observed in many countries, including Germany and the UK (Bäuerle et al., 2020; Fancourt et al., 2021; Proto and Quintana-Domeque, 2021; Smith et al., 2020). In this stressful context, there is the additional risk that people engage more in unhealthy behaviour and coping strategies, such as excessive consumption of alcohol or drugs, potentially due to insecurity and social restrictions (Clay and Parker, 2020; Marsden et al., 2020; McKay and Asmundson, 2020; Pfefferbaum and North, 2020). One of the first signs of this was the rise in supermarket sales of alcohol in the UK in response to pub and restaurant closures. In the week ending 21 March , alcohol sales rose by 67%, but total supermarket sales increased by only 43% (Finlay and Gilmore, 2020). However, reports on general alcohol consumption during the pandemic have diverse findings. Some studies reported an increase in alcohol consumption in one fifth to one third of the participants during the first weeks of the COVID-19 pandemic in spring 2020 (Daly and Robinson, 2021; Jacob et al., 2021; Taylor et al., 2021). A study in 21 European countries showed that alcohol consumption generally decreased in all countries except for the UK, where alcohol consumption increased, and Ireland, where consumption remained the same (Kilian et al., 2021). However, the literature shows that the patterns of alcohol consumption change in the course of the pandemic, that is, fewer episodes of heavy drinking (Kilian et al., 2021), but also that particular groups are at increased risk, for example, individuals with children, and those with higher depressive or anxiety scores (Sallie et al., 2020). Furthermore, people who have already had an addiction problem or other psychiatric diagnosis appear particularly at risk. Marsden and colleagues showed that while the normal population did not increase their drinking behaviour, those who already showed harmful or problematic drinking patterns increased their consumption (Marsden et al., 2020). The consumption of other substances, including legal, illegal, and prescriptive drugs, may also have increased in response to the pandemic in general (Manthey et al., 2021), and specifically to cope with COVID-19 related stress (Czeisler et al., 2020). People with a substance use disorder may increase their consumption in reaction to the negative impact of the situation, shift to other substances if access to their primary substances becomes limited, or relapse if they have already recovered from the addiction (Chiappini et al., 2020). Besides substance use, many people may also ‘escape’ from the current situation through excessive media consumption or use media excessively in search for information regarding the current situation. The media plays a particular role in how individuals cope with disasters (Taylor, 2019), which also applies to the COVID-19 pandemic. On the one hand, the media provides essential information about the virus, recent developments, and protective measures; further, social media is necessary to stay in contact with others and may also be useful to distract oneself from boredom due to a lack of alternatives (Bendau et al., 2021). On the other hand, the media may produce rumours or misinformation (Tasnim et al., 2020), or perpetuate the sense of constant threat, which may lead to increased anxiety (Garfin et al., 2020; Satici et al., 2020). Interestingly, the WHO recently started using the term ‘infodemic’ in the context of the present crisis as ‘a tsunami of misinformation, hate, scapegoating, and scare-mongering (which) has been unleashed’ (WHO, 2020). A large body of literature suggests that excessive media consumption (>3 hr daily) is associated with poorer mental health (Abbas et al., 2021; Bendau et al., 2021 Gao et al., 2020; Neophytou et al., 2019; Ni et al., 2020; Su et al., 2021; Valdez et al., 2020; Wang et al., 2020a; Zendle, 2020). In the context of the COVID-19 pandemic, most general-population studies focus on the increase of symptoms of common mental disorders, that is, depression and anxiety. The present study extends this work by also addressing the development of schizotypal traits. Our previous studies indicated an increase in schizotypic traits during the pandemic (Daimer et al., 2021; Knolle et al., 2021). Schizotypy describes a multidimensional unifying construct that represents the underlying vulnerability for schizophrenia-spectrum psychopathology that is expressed across a broad range of personality, subclinical, and clinical psychosis phenomenology (Debbané and Barrantes-Vidal, 2015; Grant and Hennig, 2020; Raine, 1991). It is regarded as a latent multidimensional personality trait that occurs in varying degrees in every person along a continuum (Grant et al., 2018). There is no consensus on the exact content of the construct, but all definitions include positive (e.g. paranoia), negative (i.e. lack of trust), and disorganised traits, similar to schizophrenia (Wright et al., 2011). The pandemic could pose an increased risk for people with pronounced schizotypal traits. For example, paranoia related to the risk of a contagious virus may result in individuals experiencing higher levels of psychological stress, depressive feelings, and anxiety (Preti et al., 2020). Fekih-Romdhane and colleagues showed that people scoring high on schizotypy were more likely to think they had COVID-19 symptoms than people with low schizotypy, and they also experienced more pronounced fear of illness (Fekih-Romdhane et al., 2021). Furthermore, a comparison between individuals with low and high schizotypy during the pandemic showed that those with low schizotypy had a variety of strategies to adaptively cope with the fear of COVID-19 (e.g. positive reframing, planning, religion, self-distraction, and behavioural disengagement), yet those with high schizotypy had fewer such strategies (Fekih-Romdhane et al., 2021). Those with high schizotypy were more likely to use maladaptive strategies such as venting or self-blame, which were less effective in reducing COVID-19 related anxiety (Fekih-Romdhane et al., 2021). Due to greater levels of introversion and mistrust of others, individuals with high schizotypal traits have fewer and poorer social contacts compared to others, are less integrated into communities, and are more likely to be lonely (Kozloff et al., 2020; Le et al., 2019). When contact with others is regarded as an additional potential risk to one’s health, schizotypal individuals may further reduce their social contacts, which may take longer to be restored in the aftermath of the pandemic (Preti et al., 2020). Additionally, individuals with high schizotypal traits may be particularly likely to succumb to media misinformation, for example, due to their low agreeableness (Kwapil et al., 2018) and disposition towards believing conspiracist ideation (Barron et al., 2014). A recent study found that people with pronounced schizotypy were more likely to share false political information (Buchanan and Kempley, 2021). Buchanan and Kempley argued that such individuals are less likely to question the truth of information than those low in schizotypy. This suggests that people scoring high on schizotypy are more likely to become victims of misinformation in the media. Misinformation due to excessive media consumption following mental health deterioration has been frequently reported during this pandemic (De Coninck et al., 2021; Su et al., 2021; Tasnim et al., 2020; Zhao and Zhou, 2020; Zhong et al., 2020). People with a high schizotypal personality are at an increased risk of developing a schizophrenic disorder (Linscott et al., 2018). According to the diathesis-stress model, environmental factors, such as major psychological stressors or stressful life events, cause the onset of psychosis in the presence of a biological predisposition to schizophrenia (Debbané and Barrantes-Vidal, 2015). The psychological stress caused by the prospect of being infected by the COVID-19 virus, as well as the social restraining measures to mitigate the virus’ spread, could potentially trigger the development of a full-blown psychosis in people with high schizotypy (Carter et al., 1995; Chapman et al., 1994; Grant and Hennig, 2020). Valdes-Florido and colleagues (2020) reported cases of psychosis triggered by the fear of infection, compulsory home-confinement or concerns about the economic consequences of the lockdown. Hu et al., 2020 reported a 25% increase in the incidence of schizophrenia in January 2020 compared to previous years in China. The authors attribute this to the psychosocial stress and social distancing measures caused by COVID-19 (Hu et al., 2020). These medium and long-term effects of COVID-19 as an adverse life event could disproportionately affect people at risk of psychosis over the next few years (Beards et al., 2013; Brown et al., 2020). In this paper, we therefore aim to investigate whether pandemic-related stressors, namely ‘COVID-19 related social adversity’ and ‘COVID-19 related life concerns’ have an effect on mental health, and whether these effects are mediated by healthy and unhealthy behaviours. We generated a separate latent model for each stressor across four samples, each collected at a different time point over a year from the start of the pandemic. We hypothesised that the separate COVID-19 stressors related to restrictions and financial concerns (‘life concerns’), and inhibited social relationships (‘social adversity’), would each be negatively associated with symptoms of common mental distress (i.e. depressive and anxiety-related symptoms), and schizotypal traits, at all time points during the pandemic. In addition, we hypothesised that this association will be mediated by healthy and unhealthy behaviours (respectively, exercise and sleep; alcohol, media, and drug consumption). Specifically, we expect that individuals who experience high levels of the above-mentioned stressors may damage their mental well-being through the unhealthy behaviours of substance use and excessive media consumption, and may improve their mental well-being through the healthy behaviours of adequate sleep and regular exercise. Materials and methods Study design and procedure Request a detailed protocol The COVID-19 exposure and COVID-19 related mental health questionnaire was designed as an online survey using EvaSys (https://www.evasys.de, Electric Paper Evaluationssysteme GmbH, Luneburg, Germany), see Knolle et al., 2021 for a detailed description. The questionnaires were available in German and English. For participant recruitment we used a snowball sampling strategy to reach the general public in Germany and the UK. The April/May 2020 survey was collected from 27 April 2020 to 31 May 2020, approximately 5 weeks after the introduction of the nationwide lockdowns in the UK and Germany. Completion of this first survey took approximately 35 min. The three follow-up surveys took only about 15 min, as they did not include question on subjective change of psychological distress (September/October 2020 survey: 10 September 2020 to 18 October 2020; January/February 2021 survey: 10 January 2021 to 7 february 2021 ; May 2021 survey: 1 May 2021 to 31 May 2021). For each cohort, the recruitment goal was 400 subjects. With this sample size, small effect sizes of f=0.02 may be detected with a power of above 80% using linear two-tailed regressions. Figure 1 shows the time point of data collection with respect to the development of cases and deaths in the UK and Germany. The subjects were contacted at the first time point via print media (i.e. Sueddeutsche Zeitung) and social media (i.e. Facebook, Twitter, and WhatsApp) and asked to forward the questionnaire to friends and family according to the snowball sampling strategy. At the following sampling time points, respondents who had provided their email address were contacted again and additional participants were recruited via social media and recruitment platforms (https://www.callforparticipants.com). Participation was voluntary, and participants did not receive any compensation. Ethical approval was obtained from the Ethical Commission Board of the Technical University Munich (250/20 S). All participants provided informed consent. Survey measures Request a detailed protocol The self-report online survey was conducted using three standardised questionnaires: the Symptom Checklist 27, the Schizotypal Personality Questionnaire (SPQ) (Raine, 1991), the CRISIS survey, and additional demographic information (age, self-reported gender, education and parental education, and living conditions). The Coronavirus Health Impact Survey (CRISIS, http://www.crisissurvey.org/)(Nikolaidis et al., 2021) was used to assessed COVID-19 exposure (infection status, symptoms, contact), subjective mental and physical health, and healthy and unhealthy behaviour (i.e. weekly amount of sleep and exercise, consumption of alcohol, drugs, and media). The survey was created by Merikangas et al., 2020 in the wake of the COVID-19 crisis in order to enable researchers and care providers to examine the extent and impact of life changes induced by the epidemic on mental health and behaviours of individuals and families across diverse international settings. A recent study using a large pilot sample from the US and UK with the CRISIS found that the results are highly reproducible and indicate a high degree of consistency in the predictive power of these factors for mental health during the COVID-19 pandemic (Nikolaidis et al., 2021).We assessed the general mental health status using the short form of the Symptom Check List (SCL-27) (Hardt et al., 2011; Hardt and Gerbershagen, 2001; Kuhl et al., 2010). The SCL’s 27 items assess symptoms of anxiety, depression, mistrust, and somatisation. It is a commonly used, economical, multidimensional screening instrument with good psychometric properties (Hardt et al., 2011; Hardt and Braehler, 2007; Kuhl et al., 2010). Finally, we assessed schizotypy using the SPQ(dichotomous version). It is a useful and widely used screening for schizotypal personality disorder in the general population (Raine, 1991). Variables and statistical analysis Request a detailed protocol Statistical analysis and visualisations were computed using R and R Studio (RStudio Team, 2020). We used Wilcoxon rank sum tests or Chi-square test of independence to explore differences between the countries (UK, Germany) and four surveys (April/May 2020, September/October 2020, January/February 2021, May 2021) on demographics and the COVID-19 exposure variables. To further explore the differences between the countries and time points in CRISIS variables we conducted robust ANOVAS (Mair and Wilcox, 2020) using the R package WRS2 with country (UK, Germany) and survey (April/May 2020, September/October 2020, January/February 2021, May 2021) as a between-subjects factor. This method was chosen because the data did not meet the parametric assumptions of ANOVA (normality, equal variance, outliers) and the robust ANOVA version is designed for non-parametric data using a maximum-likelihood estimator and therefore less sensitive to non-normality, unequal variance, and outliers compared to normal ANOVA. In order to assess the relationships between possible influences of health-damaging behaviour on depressive and anxiety-related symptoms as well as high schizotypy, we created structural equation models (SEM) using the Lavaan package in R (Rosseel, 2012). The visualisations of the models were carried out using Onyx (Brandmaier, 2021). See Figure 2 for an overview of the hypothesised models. Figure 2 Download asset Open asset Overview of the complete theoretical model for the influence of ‘social adversity’ and ‘COVID-19 related life concerns’ directly on mental health scores and indirectly via healthy and harmful behaviour variables. The same model was calculated separately for the two exogeneous variables (‘predictors’, left large box) for all four time points. The bold arrows indicate the direct pathways to the three endogenous variables (‘outcomes’). The dashed arrows indicate the indirect pathways from predictor to outcomes via the five mediators (box in the middle). Co19_concerns: COVID-19 related life concerns; Soc_adversity: social adversity; financial_I: financial impact due to the crisis; Restrictions: Perception of the restrictions as stressful; Life_Stability: Concerns about life stability due to the crisis; Change_socR: stressful social relationship changes; Neg_Thoughts: Negative Thoughts during COVID 19; ANX: anxiety symptoms; DEP: depressive Symptoms, SPQ: total sum scores of SPQ. Our three endogenous manifest variables (‘outcomes’) were schizotypy trait, symptoms of depression, and symptoms of anxiety. Schizotypal trait was defined as the total sum score of all SPQ items. For anxiety and depressive symptoms, specific items of the SCL-27 were summed and divided by the number of items. For depression, we used all SCL-27 items assessing dysthymic and depressive symptoms; and for anxiety we used all items describing agoraphobic and social phobic symptoms. For the exogeneous latent variables (‘predictors’), we generated two variables. The first variable, which we call ‘COVID-19 related life concerns’, reflects the direct impact of the pandemic on the individual’s life. The best fitting measurement model was formed using the CRISIS items ‘to what degree have changes related to the coronavirus/COVID-19 crisis in your area created financial problems for you or your family?’, ‘how stressful have the restrictions on your daily life been for you?’ and ‘to what degree are you concerned about the stability of your living situation?’. The exogeneous variables were scaled so that we fixed the variance of all factor loadings within one exogeneous latent variable to 1. This allowed comparing estimates between different models using these exogeneous latent variables quantitively. The second exogeneous latent variable, ‘social adversity’, reflects loneliness and whether change in the quality of social relationships was perceived as stressful. The variables that loaded best on the factor ‘social adversity’ were the CRISIS items ‘has the quality of the relationships between you and members of your family/social contacts changed/ how stressful have these changes in contacts been for you?’, ‘how lonely were you?’ and ‘to what extent did you have negative thoughts, thoughts about unpleasant experiences or things that make you feel bad?’. The two measurement models for the two exogeneous latent variables (predictors) had excellent fit, see Supplementary file 1a. The mediators drug use and excessive media use were recoded into dichotomous variables from categorical responses, due to sparse endorsement of some categories. Both were expressed with a positive value for at least one occasion of marijuana, opiate or tranquilliser use in the last 4 weeks, or, for at least 4 hr of daily consumption of any of social media, digital media, or video game (none at all, under 1 hr, 1–3 hr, 4–6 hr, more than 6 hr), respectively. Alcohol consumption was used as a continuous variable (not at all, rarely, once a month, several times a month, once a week, several times a week, once a day, more than once a day). Hours of sleep per night (<6 hr, 6–8 hr, 8–10 hr, >10 hr) during the week and frequency of 30 min exercise (sporting activities) per week were analysed with the original categories from the CRISIS measure. For each of the four survey time points, two separate models were conducted, one to assess how ‘social adversity’ predicted mental health scores, and the second to assess how ‘COVID-19 related life concerns’ predicted mental health scores. Mental health scores were our three endogenous variables, SPQ traits, depressive symptoms, and anxiety symptoms. Covariances between the outcome variables were included in the model, including covariances between mediators led to a non-converging model. As we hy