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The first wave of the COVID-19 pandemic in early 2020 increased mental health problems globally. However, little is known about mental health problems during a low-incidence period of the pandemic without strict public health measures.
We aim to investigate whether COVID-19–related risk factors for mental health problems persist beyond lockdown measures. We targeted a vulnerable population that is at risk of developing low mental health and assessed their daily dynamics of mood and emotion regulation after a strict lockdown.
During a postlockdown period in Germany (between August 8, 2020, and November 1, 2020), we conducted an ecological momentary assessment with 131 participants who experienced at least mild COVID-19–related distress and loneliness. To estimate negative mood inertia, we built a lag-1 three-level autoregressive model.
We found that information exposure and active daily COVID-19 cases did not have an impact on negative mood amid a postlockdown period. However, there was a day-to-day carryover effect of negative mood. In addition, worrying about COVID-19, feeling restricted by COVID-19, and feeling lonely increased negative mood.
The mental health of a vulnerable population is still challenged by COVID-19–related stressors after the lifting of a strict lockdown. This study highlights the need to protect mental health during postpandemic periods.
The COVID-19 pandemic and its associated socioeconomic consequences increased global mental health problems [
We conducted an EMA that involves repeated sampling of individuals’ current behaviors and experiences in real time and in their natural environments [
We targeted vulnerable individuals who reported at least mild psychological distress and sometimes felt lonely amid the COVID-19 pandemic. We used the COVID-19 Peritraumatic Distress Index (CPDI [
We used a smartphone app called “movisensXS” (movisens GmbH), which was developed for research purposes. The app is compliant with the General Data Protection Regulation (European Union) and Berlin Data Protection Act (Berliner Datenschutzgesetz – BlnDSG). Participants completed a 20-minute baseline assessment, followed by 7 consecutive days in which they received 8 randomized prompts between 8 AM and 10 PM. The study procedure was approved by the Ethics Committees of Charité – Universitätsmedizin Berlin (ref: EA2/143/20) and Freie Universität Berlin (ref: 030/2020).
To quantify COVID-19–related distress, we measured worries about the COVID-19 pandemic, perceived restrictions due to the COVID-19 pandemic, COVID-19 information exposure, and feelings of loneliness. Finally, we measured respondents’ momentary negative mood (anxiety, depression, fatigue, stress, and unhappiness). All questions were measured on a visual analogue scale ranging from 0 (not at all) to 100 (very much). To account for the steady increase in active COVID-19 cases in Germany during the time of measurement [
All statistical analyses were conducted in R (version 3.5.3; R Foundation for Statistical Computing [
We assessed 775 people for eligibility in an online questionnaire. The final sample size was 131 (18%; recruitment flow is shown in
Recruitment flow.
Demographics and sample characteristics.
Parameter | Values |
COVID-19 Peritraumatic Distress Index score, mean (SD) | 48.42 (16.31) |
UCLA Loneliness Scale score, mean (SD) | 22 (4.03) |
Education (in years), mean (SD) | 15.08 (3.66) |
Age (in years), mean (SD) | 31.62 (10.76) |
Gender, n (%) | Male: 49 (37); female: 82 (63) |
We used a lag-1 three-level AR model, which allows us to separate the variance of negative mood scores into variance at the person level (level 3), variance at the day level (level 2), and variance at the questionnaire level (level 1). We created two lagged variables, a within-day centered predictor at questionnaire level and a within-person centered lagged predictor at the day level. The very first beep of each day (ie, the time period between the previous day’s beep and next day’s beep) was excluded from the analysis to remove possible unexplained carryover effects resulting from the night (eg, lack of sleep). This model includes mood inertias, COVID-19 worries, COVID-19 information seeking, perceived restrictions, and loneliness during the last hour, as well as daily active COVID-19 cases as random effects. The momentary negative mood score was built by averaging momentary feelings of fatigue, anxiety, depression, unhappiness, and stress. A graphical check indicated a positive skew of negative mood; therefore, we performed a square root transformation on this variable. The analysis script can be found online at [
We found that loneliness (
Loneliness, COVID-19 worries, feelings of restriction, and day-to-day mood inertia increased negative mood. Moment-to-moment mood inertia, active COVID-19 cases, and COVID-19 information seeking did not increase negative mood. *
We found that negative effects of the COVID-19 pandemic on mental health outlast lockdown measures. In line with findings from the first COVID-19 wave [
Furthermore, we found a negative carryover effect of mood between days (mood inertia), indicating dysfunctional mood regulation. Restrictive policies during the COVID-19 pandemic can impact mental health, possibly due to impaired mood homeostasis (ie, failure to positively regulate mood via mood-modifying activities) [
Neither COVID-19 information seeking nor active COVID-19 cases increased negative mood. This contrasts with previous findings from lockdown periods [
We did not make explicit comparisons to participant status before the COVID-19 outbreak or to a control group, which limits generalizability to other populations. Furthermore, we did not measure adaptability, which has been associated with positive mood (eg, optimism and satisfaction) [
Even if cases are low and lockdown policies are lenient, mental health is still challenged by COVID-19–related stressors. Although information exposure to COVID-19 and daily COVID-19 cases had no impact on mood, we found a day-to-day carryover effect of negative mood. Moreover, COVID-19–related restriction, worry about COVID-19, and loneliness increased negative mood. Thus, the negative impact of the COVID-19 pandemic on mental health outlasts lockdown measures and mental health challenges will likely continue after the pandemic.
Supplementary materials.
autoregressive
COVID-19 Peritraumatic Distress Index
ecological momentary assessment
short-form UCLA Loneliness Scale
This research was supported by the Berlin University Alliance (grant to SL and SH).
None declared.