Mental illness and COVID-19 vaccination: a multinational investigation of observational & register-based data (preprint)

Background: Individuals with mental illness are at higher risk of severe COVID-19 outcomes. However, previous studies on the uptake of COVID-19 vaccination in this population have reported conflicting results. Therefore, we aimed to investigate the association between mental illness and COVID-19 vaccination uptake, using data from five countries. Methods: Data from seven cohort studies (N=325,298), and the Swedish registers (8,080,234), were used to identify mental illness and COVID-19 vaccination uptake. Multivariable modified Poisson regression models were conducted to calculate the prevalence ratio (PR) and 95% CIs of vaccination uptake among individuals with v.s. without mental illness. Results from the cohort studies were pooled using random effects meta-analyses. Findings: Most of the meta-analyses performed using the COVIDMENT study population showed no significant association between mental illness and vaccination uptake. In the Swedish register study population, we observed a very small reduction in the uptake of both the first (prevalence ratio [PR]: 0.98, 95% CI: 0.98-0.99, p<0.001) and second dose among individuals with mental illness; the reduction was however greater among those not using pyschiatric medication (PR: 0.91, 95% CI: 0.91-0.91, p<0.001). Conclusions: The high uptake of COVID-19 vaccination observed among individuals with most types of mental illness highlights the comprehensiveness of the vaccination campaign , however lower levels of vaccination uptake among subgroups of individuals with unmedicated mental illness warrants attention in future vaccination campaigns.

COVID-19 illness severity and 2-year prevalence of physical symptoms: an observational study in Iceland, Sweden, Norway and Denmark (preprint)

Background Persistence of physical symptoms after SARS-CoV-2 infection is a major public health concern, although evidence from large observational studies remain scarce. We aimed to assess the prevalence of physical symptoms in relation to acute illness severity up to more than 2-years after diagnosis of COVID-19. Methods This multinational study included 64 880 adult participants from Iceland, Sweden, Denmark, and Norway with self-reported data on COVID-19 and physical symptoms from April 2020 to August 2022. We compared the prevalence of 15 physical symptoms, measured by the Patient Health Questionnaire (PHQ-15), among individuals with or without a confirmed COVID-19 diagnosis, by acute illness severity, and by time since diagnosis. We additionally assessed the change in symptoms in a subset of Swedish adults with repeated measures, before and after COVID-19 diagnosis. Findings During up to 27 months of follow-up, 22 382 participants (34.5%) were diagnosed with COVID-19. Individuals who were diagnosed with COVID-19, compared to those not diagnosed, had an overall 37% higher prevalence of severe physical symptom burden (PHQ-15 score [≥] 15, adjusted prevalence ratio [PR] 1.37 [95% confidence interval [CI] 1.23-1.52]). The prevalence was associated with acute COVID-19 severity: individuals bedridden for seven days or longer presented with the highest prevalence (PR 2.25[1.85-2.74]), while individuals never bedridden presented with similar prevalence as individuals not diagnosed with COVID-19 (PR 0.92 [0.68-1.24]). The prevalence was statistically significantly elevated among individuals diagnosed with COVID-19 for eight of the fifteen measured symptoms: shortness of breath, chest pain, dizziness, heart racing, headaches, low energy/fatigue, trouble sleeping, and back pain. The analysis of repeated measurements rendered similar results as the main analysis. Interpretation These data suggest an elevated prevalence of some, but not all, physical symptoms during up to more than 2 years after diagnosis of COVID-19, particularly among individuals suffering a severe acute illness.

Elevated symptoms of depression and anxiety among family members and friends of critically ill COVID-19 patients - An observational study of five cohorts across four countries (preprint)

Background. Little is known regarding the mental health impact of having a significant person (family member and/or close friend) with COVID-19 of different severity. Methods. The study included five prospective cohorts from four countries (Iceland, Norway, Sweden, and the UK) with self-reported data on COVID-19 and symptoms of depression and anxiety during March 2020-March 2022. We calculated the prevalence ratio (PR) of depression and anxiety in relation to having a significant person with COVID-19 and performed a longitudinal analysis in the Swedish cohort to describe the temporal patterns of the results. Results. 162,237 and 168,783 individuals were included in the analysis of depression and anxiety, respectively, of whom 24,718 and 27,003 reported a significant person with COVID- 19. Overall, the PR was 1.07 (95% CI: 1.05-1.10) for depression and 1.08 (95% CI: 1.03-1.13) for anxiety among significant others of COVID-19 patients. The respective PRs for depression and anxiety were 1.04 (95% CI: 1.01-1.07) and 1.03 (95% CI: 0.98-1.07) if the significant person was never hospitalized, 1.15 (95% CI: 1.08-1.23) and 1.24 (95% CI: 1.14-1.34) if the patient was hospitalized, 1.42 (95% CI: 1.27-1.57) and 1.45 (95% CI: 1.31-1.60) if admitted to the ICU, and 1.34 (95% CI: 1.22-1.46) and 1.36 (95% CI: 1.22-1.51) if the significant person died. Individuals of hospitalized, ICU admitted, or deceased patients showed higher prevalence of depression and anxiety during the entire 12 months after the COVID-19 diagnosis of the significant person. Conclusions. Close friends and family members of critically ill COVID-19 patients show elevated prevalence of depression and anxiety throughout the first year after the diagnosis.

Use of substances to cope predicts PTSD symptom persistence: Investigating patterns of interactions between complex PTSD symptoms and its maintaining mechanisms (preprint)

Post-traumatic stress disorder (PTSD), and a novel related condition, complex PTSD, remain a growing public health challenge across the globe and are associated with negative and persistent long-term consequences. The last decades of research revealed different processes and mechanisms associated with the development and persistence of PTSD and complex PTSD symptoms, including different maladaptive coping strategies, cognitive and experiential avoidance, positive, and negative metacognitions. Despite these advances, little is known about how these different processes interact with specific (C)PTSD symptoms, and how they influence each other over time at the within-person level. Leveraging a large (N > 1,800) longitudinal dataset representative of the Norwegian population during the COVID-19 pandemic, this pre-registered study investigated these symptom-process interactions over an eight-month period. Our panel graphical vector autoregressive (GVAR) network model revealed the dominating role of substance use to cope in predicting higher levels of all different PTSD symptoms over time and being associated with increases in CPTSD symptomatology within more proximal time-windows (i.e., within six weeks). Threat monitoring was associated with increased suicidal ideation, while threat monitoring itself was increasing upon decreased avoidance behavior, greater presence of negative metacognitions, and higher use of substances to cope. In addition, our analyses revealed several, particularly strongly co-occurring PTSD symptoms and processes within the same time window (six weeks, contemporaneous associations). Our findings speak to the importance of attending to different coping strategies, particularly the use of substances as a coping behavior in efforts to prevent PTSD chronicity upon symptom onset. We outline future directions for research efforts to better understand the complex interactions and temporal pathways leading up to the development and maintenance of (C)PTSD symptomatology.

Daily Dynamics of Parental Mental Health: Investigating Depressive Symptoms and Negative Parental Experiences (preprint)

Background: Investigating psychopathological processes and how these are connected to psychiatric symptoms is important to understand how disorder states emerge and are maintained over time. Focusing on within-person relationships between variables further allows investigation of how these relations on average unfold within individuals. Methods: This preregistered intensive longitudinal study investigates connections between depressive symptoms, psychopathological processes, and negative parental experiences. Daily observations from 1036 parents were retrieved from two 40-day periods during the COVID-19 pandemic. The data was modelled using multilevel dynamic network analysis, unveiling across-day associations and contemporaneous interactions within the same time window. Results: On an across-day basis, helplessness was strongly interwoven with and predictive of the cognitive-affective features of depression and the other psychopathological processes. Being overwhelmed by the parental role (parenting stress) and emotionally drained as a parent (parental burnout) reciprocally reinforced each other from one day to the next, indicating how these components can manifest as a vicious loop over time. Finally, depressive symptomatology and negative parental experiences displayed within-day connections, with emotion regulation difficulties being connected to all parental components. Conclusions: The findings suggest that vicious cycles between helplessness and worthlessness predict the prolonged experience of depressed states in parents and that elevations in parenting stress and parental burnout reinforce each other over time.

The evolution of depressive symptomatology across three waves of the COVID-19 pandemic: A 17-month representative longitudinal study of the adult population (preprint)

This 17-month longitudinal study on a representative sample of 4,361 Norwegian adults employs an observational ABAB design across six repeated assessments and three pandemic waves to systematically investigate the evolution of depressive symptomatology across all modifications of viral mitigation protocols (VMPs) from their onset to termination. Using Latent Change Score Models to analyze 26,166 observations, the study empirically corroborates that critical fluctuations in depressive symptomatology within and across individuals occur during the first three months of the pandemic, after which symptom profiles are predominantly consolidated throughout the pandemic period. Contrary to established belief, female sex, young age, lower education and preexisting psychiatric diagnosis only served as adequate predictors of the initial shocks to symptomatology observed during the onset of the pandemic, and did not adequately predict subsequent change observed in symptoms within and across individuals. Population-level analyses demonstrated that symptom levels increased in accordance with the presence and strictness of VMPs and were unrelated to COVID-19 incidence rates. Upon predominant termination of VMPs, population-level symptoms began declining, while large heterogeneity was present across the adult population. Detrimental long-term adversities were revealed by 10% of the adults. These individuals displayed chaotic adaptation to the pandemic and its VMPs, exhibiting substantial increases in clinical levels of symptomatology ensuing partial re-opening of society and through the remainder of the pandemic, with these deleterious symptoms projected to remain heightened ahead. Frequency of quarantine exposure was incrementally tied with increases in contemporaneously experienced and long-term depressive adversities, with information obtainment through unmonitored sources further associated with contemporaneous and long-term states of heightened symptomatology.

Acute COVID-19 severity and 16-month mental morbidity trajectories in patient populations of six nations (preprint)

BACKGROUND The aim of this multinational study was to assess the development of adverse mental health symptoms among individuals diagnosed with COVID-19 in the general population by acute infection severity up to 16 months after diagnosis. METHODS Participants consisted of 247 249 individuals from seven cohorts across six countries (Denmark, Estonia, Iceland, Norway, Scotland, and Sweden) recruited from April 2020 through August 2021. We used multivariable Poisson regression to contrast symptom-prevalence of depression, anxiety, COVID-19 related distress, and poor sleep quality among individuals with and without a diagnosis of COVID-19 at entry to respective cohorts by time (0-16 months) from diagnosis. We also applied generalised estimating equations (GEE) analysis to test differences in repeated measures of mental health symptoms before and after COVID-19 diagnosis among individuals ever diagnosed with COVID-19 over time. FINDINGS A total of 9979 individuals (4%) were diagnosed with COVID-19 during the study period and presented overall with a higher symptom burden of depression (prevalence ratio [PR] 1.18, 95% confidence interval [95% CI] 1.03-1.36) and poorer sleep quality (1.13, 1.03-1.24) but not with higher levels of symptoms of anxiety or COVID-19 related distress compared with individuals without a COVID-19 diagnosis. While the prevalence of depression and COVID-19 related distress attenuated with time, the trajectories varied significantly by COVID-19 acute infection severity. Individuals diagnosed with COVID-19 but never bedridden due to their illness were consistently at lower risks of depression and anxiety (PR 0.83, 95% CI 0.75-0.91 and 0.77, 0.63-0.94, respectively), while patients bedridden for more than 7 days were persistently at higher risks of symptoms of depression and anxiety (PR 1.61, 95% CI 1.27-2.05 and 1.43, 1.26-1.63, respectively) throughout the 16-month study period. CONCLUSION Acute infection severity is a key determinant of long-term mental morbidity among COVID-19 patients.

Mechanisms associated with the trajectory of depressive and anxiety symptoms: A linear mixed-effects model during the COVID-19 Pandemic (preprint)

With the fluctuations in anxious and depressive symptomatology accompanied by the pandemic crises, studies on the trajectories of these symptom domains are warranted to monitor the development of mental health problems in the population. This pre-registered longitudinal study examines stable factors and mechanistic processes covarying with the trajectory of anxiety and depressive symptoms using linear-mixed effects models in 4936 adults from the pandemic’s onset to four months into the COVID-19 pandemic in Norway. Prevalence estimates of moderate to severe levels of clinically impairing symptoms of anxiety and depression revealed high but reduced occurrence four months into the pandemic where social distancing protocols were substantially lightened in severity, revealing associations between symptoms and viral mitigation protocols after stringent control of plausible confounders. In risk subgroups at the onset of the pandemic sustained their relative position compared to their counterparts four months into the pandemic, indicating prolonged suffering of these subgroups. Among mechanistic processes, key differences were identified regarding the trajectory of anxiety and depressive symptoms. Physical exercise was associated with long-term but not momentaneous alleviations in anxiety. In contrast, reductions in depressive symptoms were associated with both the simultaneous exertion as well as dose-increases in exercise over time. Increased knowledge about how to best cope with pandemic challenges was associated with greater improvement in depressive but not anxiety symptoms. Reductions in maladaptive coping strategies and negative metacognitive beliefs was substantially associated with greater improvement of both anxious and depressive symptomatology. Mechanistic processes divergently relate to the trajectory of depressive and anxious symptomatology, yielding domain-specific information of utility for preventive and interventive efforts aimed at impeding deleterious symptom levels.

Within and across-day patterns of interplay between depressive symptoms and related psychopathological processes: A dynamic network approach during the COVID-19 pandemic (preprint)

Background: In order to understand the intricate patterns of interplay connected to the formation and maintenance of depressive symptomatology, repeated measures investigations focusing on within-person relationships between psychopathological mechanisms and depressive components are required. Methods: This large-scale preregistered intensive longitudinal study conducted 68 240 observations of 1706 individuals in the general adult population across a 40-day period during the COVID-19 pandemic to identify the detrimental processes involved in depressive states. Daily responses were modeled using multi-level dynamic network analysis to investigate temporal associations across days, in addition to contemporaneous relationships between depressive components within a daily window. Results: Among the investigated psychopathological mechanisms, helplessness predicted the strongest across-day influence on depressive symptoms, while emotion regulation difficulties displayed more proximal interactions with symptomatology. Helplessness was further involved in the amplification of other theorized psychopathological mechanisms including rumination, the latter of which to a greater extent was susceptible toward being influenced rather than temporally influencing other components of depressive states. Distinctive symptoms of depression behaved differently, with depressed mood and anhedonia most prone to being impacted, while lethargy and worthlessness were more strongly associated with outgoing activity in the network. Conclusions: The main mechanism predicting amplifications of detrimental symptomatology was helplessness. Lethargy and worthlessness revealed greater within-person carry-over effects across days, providing preliminary indications that these symptoms may be more strongly associated with pushing individuals toward prolonged depressive state experiences. The psychopathological processes of rumination, helplessness, and emotion regulation only exhibited interactions with the depressed mood and worthlessness component of depression, being unrelated to lethargy and anhedonia. The findings have implications for the impediment of depressive symptomatology during and beyond the pandemic period. They further outline gaps in the literature concerning the identification of psychopathological processes intertwined with lethargy and anhedonia on the within-person level.

Feelings of Worthlessness Links Depressive Symptoms and Parental Stress: A Network Analysis During the COVID-19 Pandemic (preprint)

The prevalent co-occurrence between parental stress and depression has been previously established prior to and during the COVID-19 pandemic outbreak. However, no studies to date have identified the connections through which these symptom domains interact with each other to emerge into a complex and detrimental mental health state, along with the plausible mechanistic variables that may play key roles in maintaining parental stress and depression. The aim of this research is to uncover these interactions in a period where parents experience heighted demands and stress as a consequence of the strict social distancing protocols. Network analysis is utilized to examine parental stress and depressive symptoms during the COVID-19 pandemic in a large cross-sectional study (N = 2868) of parents. Two graphical Gaussian graphical network models were estimated, one in which only parental stress and depression symptoms were included, and another in which several mechanistic variables were added. Expected influence and bridge expected influence revealed that feeling worthless was the most influential node in the symptoms network and bridged the two psychological states. Among the mechanistic variables, worry and rumination was specifically relevant in the depressive cluster of symptoms, and self-criticism was connected to both constructs. The study display that the co-occurrence of parental stress and depression have specific pathways, were manifested through feelings of worthlessness, and have specific patterns of connection to important mechanisms of psychopathology. The results are of utility when aiming to avoid the constellation of co-occurring parental stress and depressive symptoms during the pandemic.

Risk, Trust, and Flawed Assumptions: Vaccine Hesitancy During the COVID-19 Pandemic (preprint)

Background: The pace at which the present pandemic and future public health crises involving viral infections are eradicated heavily depends on the availability and routine implementation of vaccines. This process is further affected by a willingness to vaccinate, embedded in the phenomenon of vaccine hesitancy. The World Health Organization has listed vaccine hesitancy among the greatest threats to global health, calling for research to identify the factors associated with this phenomenon. Methods: The present study seeks to investigate the psychological, contextual, and sociodemographic factors associated with vaccination hesitancy in a large sample of the adult population. 4571 Norwegian adults were recruited through an online survey between January 23 to February 2, 2021. Subgroup analyses and multiple logistic regression was utilized to identify the covariates of vaccine hesitancy. Results: Several subgroups hesitant toward vaccination were identified, including males, rural residents, and parents with children below 18 years of age. No differences were found between natives and non-natives, across education or age groups. Individuals preferring unmonitored media platforms (e.g., information from peers, social media, online forums, and blogs) more frequently reported hesitance towards vaccination than those relying on information obtainment from source-verified platforms. Perceived risk of vaccination, belief in the superiority of natural immunity, fear concerning significant others being infected by the virus, and trust in health officials’ dissemination of vaccine-related information were identified as key variables related to vaccine hesitancy. Conclusions: Given the heterogeneous range of variables associated with vaccine hesitancy, additional strategies to eradicate vaccination fears are called for aside from campaigns targeting the spread of false information. Responding to affective reactions in addition to involving other community leaders besides government and health officials present promising approaches that may aid in combating vaccination hesitation.

Emotion regulation difficulties and interpersonal problems during the COVID-19 Pandemic: Predicting anxiety and depression (preprint)

Background: Central components of psychological functioning, such as difficulties in emotion regulation and interpersonal problems are likely to have been substantially impacted by COVID-19 and the amelioration measures of societal lock-down and social distancing. In turn, these factors are likely to predict mental health outcomes, such as symptoms of depression and anxiety throughout the pandemic and beyond. Methods: To investigate this issue, we conducted an internet-based survey with 10,061 responders at the height of lock-down (T1). After social distancing measures had been eased (T2), 4,936 responders (49.1%) completed the survey again. Results: Emotion regulation difficulties, interpersonal problems, and symptoms of depression and anxiety decreased from T1 to T2, but changes were minor. After controlling for age and gender, emotion regulation- and interpersonal difficulties were associated with anxiety and depression throughout the study period, and changes in all domains occurred in concert. More extensive problems with emotion regulation at T1 predicted greater reductions in both symptom domains as amelioration measures were eased, while the converse was true for interpersonal problems. Furthermore, the impact of initial emotion regulation difficulties on subsequent changes in both anxiety- and depressive symptoms was dependent on the level of interpersonal difficulties, so that high interpersonal problem load at T1 reversed the effect of emotion regulation difficulties on symptom development. Conclusions: The results suggest that emotion regulation- and interpersonal difficulties are highly central to mental health during the pandemic, and may be important targets for remediation to reduce mental health problems throughout the course of the pandemic and beyond.

Information Dissemination and the COVID-19 Pandemic: The Relationship between Different Information Sources and Symptoms of Psychopathology (preprint)

The 2020-2021 COVID-19 pandemic has added to the mental health strain on individuals and groups across the world. Viral mitigation protocols and viral spread affect millions every day, but to widely different degrees. How individuals gather information about the pandemic might have an effect on levels of mental distress in the population. In this cross-sectional and representative study of the adult population of Norway, findings suggest that information gathered through newspapers and social media are the information pathways with the strongest association to symptoms of anxiety, depression and health anxiety with small to medium effect sizes. However, avoiding information about the pandemic had larger effect sizes related to symptoms of psychopathology than acquiring information about the pandemic from any source. The results suggest that to reach those who avoid pandemic news is an important goal, both to ensure the population as a whole gets relevant information regarding current viral mitigation protocols, that may in turn alleviate stress, and thus reduce the likelihood of viral transmission. The spread of pandemic misinformation on social media and the internet must be buffered, and successful interventions against misinformation may affect the mental health of the population.

Mechanisms of Parental Stress During and After the COVID-19 Lockdown: A two-wave longitudinal study (preprint)

Background: In the unpredictable times of the ongoing global coronavirus disease (COVID-19), parents worldwide are affected by stressors and strains that follow in the wake of the government-initiated distancing protocols. Objective: In a two‐wave longitudinal survey, we examined levels of parental perceived stress and symptoms of anxiety and depression among a sample of parents at two time points; in the midst of the strictest government-initiated physical distancing protocols following the onset of the COVID-19 pandemic (T1, N = 2868) and three months after the protocols discontinued (T2, n = 1489). Further, we investigated the levels of parental stress, anxiety, and depression relative to perceived relationship quality and anger aimed at child(ren) at the two time points, including subgroups based on age, sex, cultural background, civil status, education level, number of children in household, employment status, and pre-existing psychiatric diagnosis.Methods and findings:Parents were asked to fill out a set of validated questionnaires on the two measurement occasions. As expected, the findings indicate that the high levels of parental stress significantly decreased from T1 to T2, indicating that the cumulative stressors that parent’s experiences during distancing protocols declined as a function of the phaseout of the protocols. The decrease of perceived parental stress at the two time points, was accompanied by a significant decrease in symptoms of both depression and anxiety among the participating parents. Symptoms meeting the clinical cut-off for depression (23.0%) and generalized anxiety disorder (23.3%) were reported among participating parents at T1, compared to 16.8% and 13.8% respectively at T2. Reduction in depression and angry at child(ren) from T1 to T2 were further associated with a reduction in perceived parental stress. In addition, relationship quality and angry at child(ren) at T1 predicted change in parental stress. Conclusions: The findings underline some of the negative psychological impact of physical distancing protocols on parent’s health and well-being. Parents who are facing physical distancing and remaining at home with their children may be particularly vulnerable to parental stress, anxiety and depression. Uncovering the nature of how these constructs are associated to parents and families facing social crisis, such as the ongoing pandemic, can contribute to design relevant interventions to reduce parental stress and strengthen parental coping and resilience. Keywords: COVID-19 lockdown, parental stress, anxiety, depression, social distancing.

The network structure of stress-related states, depression, and anxiety symptoms during the COVID-19 lockdown (preprint)

Background. The coronavirus (COVID-19) pandemic and the social distancing protocols used to impede the spread of the virus may have severe mental health consequences. The purpose of this study was to investigate the network of components of pandemic-related negative psychological states (i.e., fear of infection, financial worries, loneliness) and symptoms of major depressive disorder (MDD) and generalized anxiety disorder (GAD).Methods. Data from 10,061 Norwegian adults recruited through an online survey during a period of strict social distancing protocols were analyzed employing a cross-sectional Gaussian Graphical Model.Results. Of the infection fears, fear of being infected, fear of dying from the coronavirus and fear of significant others dying from it had notable connections to the GAD symptoms anxiety and/or fear of awful events. The financial worry component worry about personal economy was connected to the MDD symptom sleep problems and to the GAD symptom generalized worry. Each of the loneliness components was connected to a specific MDD symptom. Anhedonia, depressed mood and worthlessness had the highest strength centrality among the MDD symptoms; generalized worry, uncontrollability of worry, and trouble relaxing among the GAD symptoms; fear of dying from the virus among the fear of infection components; and feeling isolated among the loneliness components. A community analysis identified separate clusters for MDD and GAD as well as a cluster cutting across the two disorders. Conclusions. Particular components of the pandemic-related distressing states of fear of infection and loneliness seem to be associated with specific symptoms of MDD and GAD.Key words: COVID-19; fear of infection; financial worry; loneliness; major depressive disorder symptoms; generalized anxiety disorder symptoms; cross-sectional network analysis

Parenting in a Pandemic: Parental Stress During the Physical Distancing Intervention Following the onset of the COVID-19 Outbreak (preprint)

Objective: The main aim of the study was to examine levels of parental stress and symptoms of depression and anxiety in the general parental population (N = 2868) during the strict government-initiated physical distancing protocols following the onset of the COVID-19 pandemic. We further investigated specific predictors of parental distress, including burnout, anger aimed at children, worry, lack of social support, lower perceived self-efficacy, and difficulty to work from home. Method: In this cross-sectional, epidemiological study, we disseminate an online survey that was administered two weeks after the government-initiated physical distancing protocols were established. Data were collected from March 31 to April 7. Results: Female parents compared to male parents and parents living with more than one child per parent or child(ren) with special needs compared to those living with one or fewer children per parent reported higher levels of parental stress. Burnout and social support were further associated with parental stress. Specifically, nearly one-fourth of the parents reported that they have felt burned out or in the proximity of feeling burned out more than half the days during the social distancing interventions. Also, 29% of the parents reported that they were angrier at their child(ren) than usual during the physical distancing period.Parents with a pre-existing psychiatric diagnosis had significantly higher parental stress compared to individuals with no psychiatric diagnosis. The reported prevalence of depression and anxiety symptoms above standardized cutoff levels among the 2868 parents was 25.4% for depression and 24.1% for anxiety, with the highest prevalence score on both symptoms of anxiety (37.6%) and depression (38.5%) for the youngest parents (age group 21–30 years). Furthermore, the parents who were home with their children and predominantly followed distancing protocol by socially distancing from public activity and peers (i.e., at least 10 out of 14 days) had significantly higher symptoms of depression (29%) and anxiety (27%), compared to parents who did not isolate in the same manner (i.e., depression 13% and anxiety 15%). Conclusions: The present study reveals that home confinement during the restricted lockdown period is related to markedly high levels of parental stress, in addition to symptoms of depression and anxiety in parents. Given the detrimental effects of depression, anxiety, and parental stress on the quality of life, morbidity rates, as well as adverse child outcomes and the potential risk of child abuse and neglect, these results suggest that appropriate action should be taken to impede further development of these symptoms, as well as developing interventions aimed at vulnerable subgroups and other relevant factors associated with increased parental stress. Keywords: COVID-19 lockdown, parental stress, depression, anxiety

Factors associated with Adherence to Social Distancing Protocols and Hygienic Behavior during the COVID-19 Pandemic (preprint)

Objective: To investigate factors associated with adherence to viral mitigation strategies recommended by the WHO during the COVID-19 pandemic, including adherence to social distancing protocols (SDPs) and adherence to hygienic behavior recommendations (HB). Design: This pre-registered epidemiological study of 4158 adults examines the association between situational, cognitive, affective, behavioral, and personality-based factors with adherence to SDPs and HB during the COVID-19 pandemic. The study further investigates the relationship between central information sources and adherence behavior.Main Outcome Measures: Adherence to social distancing protocols (SDPs) and adherence to hygienic behavior recommendations (HB). Results: Individuals aged between 18-30 reported lowest adherence to SDPs and HB. Greater alcohol consumption was associated with decreased adherence to SDP and HB. Increased risk perception, fear of infection, conscientious personality, and altruistic attitude was associated with greater adherence to SDPs and HB. Males, single individuals, employed individuals, and those without children reported lower adherence to SDPs and HB. Extroverted personality and residents of urban areas were associated with lower adherence to SDPs, but not HB. In contrast to earlier stages of the pandemic, voluntary social distancing was associated with greater adherence to SDPs as opposed to rule-enforced (e.g., mandated) social distancing. Among information sources, increased time spent obtaining information from official (i.e., recognized) newspapers had the strongest favorable association with adherence to both SDPs and HB, followed by information obtainment from recognized television channels. Relying on information from friends and family was associated with decreased adherence to SDPs, but was unrelated to adherence to HB. Sensitivity analyses replicated the findings, supporting the stability and robustness of the proposed models. Conclusion: The present study identifies factors associated with favorable and detrimental adherence behavior along with substantial dissemination routes, presenting strategies which may be utility toward fostering adherence to contemporaneously implemented pandemic mitigation protocols.Key words: COVID-19; Adherence; Compliance; Social Distancing; Physical Distancing; Viral Mitigation; Hygienic Behavior

Loneliness and social distancing during the COVID-19 pandemic: Risk factors and associations with psychopathology (preprint)

Background: The mitigation strategies employed against the COVID-19 pandemic have severe mental health consequences. In particular, as a result of the social distancing protocols, loneliness is likely to increase. This study investigates (a) potential risk and resilience factors for loneliness in the Norwegian population during the strict social distancing non-pharmacological interventions (NPIs) implemented against the pandemic and (b) the associations between loneliness and psychopathology symptoms. Methods: A survey was disseminated online to the adult Norwegian population when strict social distancing measures had been implemented for two weeks. The resulting sample of 10061 respondents was unproportionate in terms of gender and educational level and thus sensitivity analyses were conducted. The levels of loneliness were compared across demographic sub-groups, and regression analyses were conducted to identify potential risk and resilience factors for loneliness and associations between loneliness and psychopathology symptoms. Results: Among the stable factors, being single and having a psychiatric diagnosis were related to more loneliness with small effect sizes. Among the state risk factors, more rumination and worry in general were associated with stronger loneliness, showing a medium effect size. Among the coping behaviors examined, doing new things at home not done otherwise was negatively related to loneliness, with a small effect size. Loneliness was associated with both depression and anxiety with small effect sizes when all potential confounders and psychiatric diagnosis were controlled for. The relationship to depression was more marked than the relationship to anxiety. Conclusions: The findings suggest that singles and those with a psychiatric diagnosis were most affected by loneliness during the implementation of social distancing measures to impede the coronavirus. The results support the link between loneliness and depression and anxiety symptoms. The results of the analysis of potential risk and resilience factors point to intervention targets for reducing loneliness during pandemic crises. Keywords: loneliness, risk factors, resilience factors, depression, anxiety, COVID-19, social distancing measures

PTSD symptoms among health workers and public service providers during the COVID-19 outbreak (preprint)

In the frontline of the pandemic stand healthcare workers and public service providers, occupations which have proven to be associated with increased mental health problems during pandemic crises. This cross-sectional, survey-based study collected data from 1773 healthcare workers and public service providers throughout Norway between March 31, 2020 and April 7, 2020, which encompasses a timeframe where all non-pharmacological interventions (NPIs) were held constant. Post-traumatic stress disorder (PTSD), anxiety and depression were assessed by the Norwegian version of the PTSD checklist (PCL-5), General Anxiety Disorder –7, and Patient Health Questionnaire-9 (PHQ-9), respectively. Health anxiety and specific predictors were assessed with specific items. Multiple regression analysis was used for predictor analysis. A total of 28.9% of the sample had clinical or subclinical symptoms of PTSD, and 21.2% and 20.5% were above the established cut-offs for anxiety and depression. Those working directly in contrast to indirectly with COVID-19 patients had significantly higher PTSD symptoms. Worries about job and economy, negative metacognitions, burnout, health anxiety and emotional support were significantly associated with PTSD symptoms, after controlling for demographic variables and psychological symptoms. Health workers and public service providers are experiencing high levels of PTSD symptoms, anxiety and depression during the COVID-19 pandemic. Health workers working directly with COVID-19 patients have significantly higher levels of PTSD symptoms and depression compared to those working indirectly. Appropriate action to monitor and reduce PTSD, anxiety, and depression among these groups of individuals working in the frontline of pandemic with crucial societal roles should be taken immediately.

The mental health impact of non-pharmacological interventions aimed at impeding viral transmission during the COVID-19 pandemic in a general adult population and the factors associated with adherence to these mitigation strategies (preprint)

This epidemiological investigation assesses the prevalence of depression and anxiety symptoms during the COVID-19 pandemic. A total of 10,061 adults participated in the study. Symptoms of depression and anxiety were two to three times higher compared to pre-pandemic samples. Those who predominantly socially distanced themselves revealed substantially higher symptoms than their counterparts. Females, ethnic and sexual orientation minorities, younger adults, unemployed individuals, and those with a psychiatric diagnosis reported higher prevalence of psychological symptoms. Worry about prolonged duration of physical distancing protocols and frustration of autonomy was associated with elevation in symptoms of depression and anxiety. Increased competence to deal with the crisis was associated with less adverse symptoms. Physical exercise, experiencing nature, and distraction with activities were associated with less depressive symptoms, but not anxiety. The extent of information access about the pandemic was associated with reduced anxiety symptoms. Furthermore, adherence to mitigation protocols was investigated. Younger adults and males reported lowest adherence. Altruistic attitudes, in addition to mandatory as opposed to voluntary adherence was associated with higher adherence. Worrying about significant others’ health was associated with higher, while worry about duration of pandemic protocols was associated with lower adherence rates.