The impact of COVID-19 lockdown on a cohort of adults with recurrent major depressive disorder from Catalonia: a decentralized longitudinal study using remote measurement technology (preprint)

The present study analyzes the effects on depression levels of each containment phase of the first wave of COVID-19 in a cohort of adults with a history of major depressive disorder (MDD). This analysis is part of the Remote Assessment of Disease and Relapse-MDD (RADAR-MDD) study. Depression was evaluated with the Patient Health Questionnaire-8 (PHQ-8) and anxiety with the Generalized Anxiety Disorder-7 (GAD-7). A total of 121 participants from Catalonia were registered from November 1, 2019, to October 16, 2020. Levels of depression were explored across the phases (pre-lockdown, lockdown, four post-lockdown phases) of the restrictions imposed by the Spanish/Catalan governments. Then, a mixed model was fitted to estimate how depression varied over the phases. A significant rise in the depressive severity was found during the lockdown and phase 0 (early post-lockdown), as compared with pre-lockdown phase in this sample with a history of MDD. Those with low pre-lockdown depression experienced a higher increase in depression levels during the new-normality. We observed a significant decrease in the depression levels during the new-normality in those with high pre-lockdown depression, compared to the pre-lockdown period. These findings suggest that COVID-19 restrictions impacted on the depression of individuals diagnosed with MDD, depending on their pre-lockdown depression levels.

Biopsychosocial response to the COVID-19 lockdown in people with major depressive disorder and multiple sclerosis. (preprint)

BackgroundChanges in lifestyle, finances and work status during COVID-19 lockdowns may have led to biopsychosocial changes in people with pre-existing vulnerabilities such as Major Depressive Disorders (MDD) and Multiple Sclerosis (MS). MethodsData were collected as a part of the RADAR-CNS (Remote Assessment of Disease and Relapse - Central Nervous System) programme. We analyzed the following data from long-term participants in a decentralized multinational study: symptoms of depression, heart rate (HR) during the day and night; social activity; sedentary state, steps and physical activity of varying intensity. Linear mixed-effects regression analyses with repeated measures were fitted to assess the changes among three time periods (pre, during and post-lockdown) across the groups, adjusting for depression severity before the pandemic and gender. ResultsParticipants with MDD (N=255) and MS (N=214) were included in the analyses. Overall, depressive symptoms remained stable across the three periods in both groups. Lower mean HR and HR variation were observed between pre and during lockdown during the day for MDD and during the night for MS. HR variation during rest periods also decreased between pre-and post-lockdown in both clinical conditions. We observed a reduction of physical activity for MDD and MS upon the introduction of lockdowns. The group with MDD exhibited a net increase in social interaction via social network apps over the three periods. ConclusionsBehavioral response to the lockdown measured by social activity, physical activity and HR may reflect changes in stress in people with MDD and MS.

Heterogeneity in the Effectiveness of Non-pharmaceutical Interventions During the First SARS-CoV2 Wave in the United States.

Background: Attempts to quantify effect sizes of non-pharmaceutical interventions (NPI) to control COVID-19 in the US have not accounted for heterogeneity in social or environmental factors that may influence NPI effectiveness. This study quantifies national and sub-national effect sizes of NPIs during the early months of the pandemic in the US. Methods: Daily county-level COVID-19 cases and deaths during the first wave (January 2020 through phased removal of interventions) were obtained. County-level cases, doubling times, and death rates were compared to four increasingly restrictive NPI levels. Socio-demographic, climate and mobility factors were analyzed to explain and evaluate NPI heterogeneity, with mobility used to approximate NPI compliance. Analyses were conducted separately for the US and for each Census regions (Pacific, Mountain, east/West North Central, East/West South Central, South Atlantic, Middle Atlantic and New England). A stepped-wedge cluster-randomized trial analysis was used, leveraging the phased implementation of policies. Results: Aggressive (level 4) NPIs were associated with slower COVID-19 propagation, particularly in high compliance counties. Longer duration of level 4 NPIs was associated with lower case rates (log beta -0.028, 95% CI -0.04 to -0.02) and longer doubling times (log beta 0.02, 95% CI 0.01-0.03). Effects varied by Census region, for example, level 4 effects on doubling time in Pacific states were opposite to those in Middle Atlantic and New England states. NPI heterogeneity can be explained by differential timing of policy initiation and by variable socio-demographic county characteristics that predict compliance, particularly poverty and racial/ethnic population. Climate exhibits relatively consistent relationships across Census regions, for example, higher minimum temperature and specific humidity were associated with lower doubling times and higher death rates for this period of analysis in South Central, South Atlantic, Middle Atlantic, and New England states. Conclusion and Relevance: Heterogeneity exists in both the effectiveness of NPIs across US Census regions and policy compliance. This county-level variability indicates that control strategies are best designed at community-levels where policies can be tuned based on knowledge of local disparities and compliance with public health ordinances.

Changes in health behaviors, mental and physical health among older adults under severe lockdown restrictions during the COVID-19 pandemic in Spain (preprint)

Background: We aimed to examine main changes in health behaviors, mental and physical health among older adults under severe lockdown restrictions during the COVID-19. Methods: We used prospective data from 3041 participants in four cohorts of community-dwelling individuals aged [≥]65 years in Spain. Data were obtained using validated questionnaires through a pre-pandemic face-to-face interview and a telephone interview conducted between weeks 7 to 15 after the beginning the COVID-19 lockdown. Lineal or multinomial, as appropriate, regression models with adjustment for the main confounders were used to assess changes in the outcome variables from the pre-pandemic to the confinement period, and to identify their associated factors. Results: On average, the confinement was not associated with a deterioration in lifestyle risk factors (smoking, alcohol intake, diet or weight), except for a decreased physical activity and increased sedentary time, which reversed with the end of confinement. However, chronic pain worsened, and moderate declines in mental health, that did not seem to reverse after restrictions were lifted, were observed. Several subgroups of individuals were at increased risk of developing unhealthier lifestyles or mental health decline with confinement: (i)-males (for physical activity and sedentariness), (ii)-those with greater social isolation (for diet, physical activity, mental health), (iii)-feelings of loneliness (for diet, sleep quality, mental health), (iv)-poor housing conditions (for diet, physical activity, TV viewing time), (v)-unhealthy sleep duration (for physical activity and sedentariness), and (vi-worse overall health or chronic morbidities (for physical activity, screen time, mental health). On the other hand, previously having a greater adherence to the Mediterranean diet and doing more physical activity protected older adults from developing unhealthier lifestyles with confinement. Conclusions: The lockdown during the first wave of the COVID-19 in Spain, which was one of the most restrictive in Europe, only led to minor average changes in health behaviors among older adults. However, mental health was moderately affected. If another lockdown were imposed on this or future pandemics, public health programs should specially address the needs of older individuals with male sex, greater social isolation, poor housing conditions and chronic morbidities, because of their greater vulnerability to the enacted movement restrictions

Government Interventions and Control Policies to Contain COVID-19 Outbreak: Global Analysis of Evidence During the First 4 Months (preprint)

Background: The overarching aim of this study was to evaluate the effectiveness over time of government interventions, policy restrictions, and the impact of risk factors on COVID-19 spread and mortality, globally, regionally and by country-income level, through May 18th. Additionally, we used Italy, South Korea, and Spain to illustrate critical time-points when government interventions could have been applied to achieve maximal COVID-19 prevention. Methods: We created a global database merging WHO daily case reports (from 218 countries/territories) with other socio-demographic and population health measures from January 21 st to May 18th, 2020. A 4-level government policy interventions score was created that varied from 0 to 3 representing “low”, “intermediate”, “high”, and “very-high” interventions. Findings: Our results support use of very high government interventions to effectively suppress both COVID-19 spread and mortality, globally compared to other policy levels of control. Additionally, we found that only very-high level government interventions suppressed COVID-19 mortality close to pre-intervention estimates. Similar trends in virus propagation and mortality were observed in all country-income levels and specific regions. An inverse relationship with intensive care beds and mortality was also found. Interpretation: Rapid implementation of government interventions are needed to contain the COVID-19 outbreak and reduce COVID-19 related mortality.Funding Statement: No funding was received for this study. Declaration of Interests: The authors report no relationships that could be construed as a conflict of interest. Ethics Approval Statement: The study’s protocol has been approved by the research ethics board at the Parc Sanitari Sant Joan de Déu (PIC-67-20, Barcelona, Spain).

COVID-19: Effectiveness of Non-Pharmaceutical Interventions in the United States before Phased Removal of Social Distancing Protections Varies by Region (preprint)

Although coronavirus disease 2019 (COVID-19) emerged in January 2020, there is no quantified effect size for non-pharmaceutical interventions (NPI) to control the outbreak in the continental US. Objective. To quantify national and sub-national effect sizes of NPIs in the US. Design. This is an observational study for which we obtained daily county level COVID-19 cases and deaths from January 22, 2020 through the phased removal of social distancing protections. A stepped-wedge cluster-randomized trial (SW-CRT) analytical approach is used, leveraging the phased implementation of policies. Data include 3142 counties from all 50 US states and the District of Columbia. Exposures. County-level NPIs were obtained from online county and state policy databases, then classified into four intervention levels: Level 1 (low), declaration of a State of Emergency; Level 2 (moderate), school closures, restricting nursing home access, or closing restaurants and bars; Level 3 (high), non-essential business closures, suspending non-violent arrests, suspending elective medical procedures, suspending evictions, or restricting mass gatherings of at least 10 people; and Level 4 (aggressive). sheltering in place / stay-at-home, public mask requirements, or travel restrictions. Additional county-level data were obtained to record racial (Black, Hispanic), economic (educational level, poverty), demographic (rural/urban) and climate factors (temperature, specific humidity, solar radiation). Main Outcomes. The primary outcomes are rates of COVID-19 cases, deaths and case doubling times. NPI effects are measured separately for nine US Census Region (Pacific, Mountain, West North Central, East North Central, West South Central, East South Central, South Atlantic, Middle Atlantic, New England). Results. Aggressive NPIs (level 4) significantly reduced COVID-19 case and death rates in all US Census Regions, with effect sizes ranging from 4.1% to 25.7% and 5.5% to 25.5%, respectively, for each day they were active. No other intervention level achieved significance across all US Regions. Intervention levels 3 and 4 both increased COVID-19 doubling times, with effects peaking at 25 and 40 days after initiation of each policy, respectively. The effectiveness of level 3 NPIs varied, reducing case rates in all regions except North Central states, but associated with significantly higher death rates in all regions except Pacific states. Intervention levels 1 and 2 did not indicate any effect on COVID-19 propagation and, in some regions, these interventions were associated with increased COVID-19 cases and deaths. Heterogeneity of NPI effects are associated with racial composition, poverty, urban-rural environment, and climate factors. Conclusion. Aggressive NPIs are effective tools to reduce COVID-19 propagation and mortality. Reducing social and environmental disparities may improve NPI effects in regions where less strict policies are in place.