985580 research-article2020 HPQ0010.1177/1359105320985580Journal of Health PsychologyCastellano-Tejedor et al. Research article Journal of Health Psychology Psychological impact in the time 1­–16 © The Author(s) 2021 Article reuse guidelines: of COVID-19: A cross-sectional sagepub.com/journals-permissions DOI: 10.1177/1359105320985580 https://doi.org/10.1177/1359105320985580 population survey study during journals.sagepub.com/home/hpq confinement Carmina Castellano-Tejedor1,2,3 , María Torres-Serrano2 and Andrés Cencerrado1,4 Abstract The transformation that COVID-19 has brought upon the world is unparalleled. The impact on mental health is equally unprecedented and yet unexplored in depth. An online-based survey was administered to 413 community-based adults during COVID-19 confinement to explore psychological impact and identify high risk profiles. Young females concerned about the future, expressing high COVID-related distress, already following psychological therapy and suffering from pre-existing chronic conditions, were those at highest risk of psychological impact due to the COVID-19 situation. Findings could be employed to design tailored psychological interventions in the early stages of the outbreak to avoid the onset/exacerbation of psychopathology. Keywords COVID-19, cross-sectional survey, non-pharmaceutical interventions, online survey, pandemic, population mental health, psychological impact, quarantine Introduction the relatively high mortality, causes the popula- tion to begin to worry about the COVID-19. The world has faced a global threat in the last months from the Coronavirus disease 2019 (COVID-19) caused by the SARS-CoV-2, 1  synaptic, Psicología y Servicios Científicos y P emerging into a pandemic with generalized Tecnológicos S.L.P., Spain health and socio-economic consequences. The 2 GIES Research Group, Basic Psychology Department, transformation that this pandemic has brought Autonomous University of Barcelona, Spain 3 upon the society is unparalleled, and the impact Research Group on Aging Frailty and Care Transitions (REFiT) Parc Sanitari Pere Virgili & Vall d’Hebron on mental health is equally unprecedented and Research Institute, Spain therefore, unexplored. With huge contagion 4 Mitiga Solutions S.L., Spain capacity, COVID-19 mortality around the world Corresponding author: is up to 4% (lower than previous SARS, but not Carmina Castellano-Tejedor, GIES Research Group, trivial), and directly related to age and immune- Basic Psychology Department, Autonomous University of compromised states (Standl et al., 2020). Barcelona, B5-114, Edifici B, 08192 Bellaterra, Spain. Precisely, this extremely high infection rate and Email: carmina.castellano@uab.es 2 Journal of Health Psychology 00(0) In the early stages of an infectious disease and Canada during the outbreak of Severe outbreak such as COVID-19, there is frequent Acute Respiratory Syndrome (SARS), whereas uncertainty about the nature of the disease, its entire villages in many West African countries spread, scope, and potential impact. Indeed, were quarantined during the 2014 Ebola fear and worry of contacting individuals who outbreak. are possibly infected by COVID-19 has been While all these non-pharmacological inter- reported as a common response pattern to the ventions (NPIs) can broadly serve the public still developing COVID-19 crisis (Lin, 2020; good, they might cause significant disruption Zysberg & Zisberg, 2020). Fear is directly asso- globally, and have been directly associated with ciated with its transmission rate and medium psychological challenges for those isolated, (rapidly and invisibly), as well as its morbidity their loved ones and the healthcare workers car- and mortality. This further leads to other psy- ing for them (Ni et al., 2020; Rodríguez-Rey chosocial challenges including stigmatization et al., 2020). Besides, common psychological and discrimination (Islam et al., 2020). and behavioral responses from general popula- Additionally, with high levels of fear, individu- tion in front of health crises include several dis- als may not think clearly and rationally when tress reactions (insomnia, anxiety, decreased reacting to COVID-19 (Perini, 2012). Taken perception of safety, anger, scapegoating, and together, these factors (fear and COVID-related increased recurrence to healthcare centers due concerns) could contribute substantially to an to fears of illness), and health risk behaviors individual profile that experiences greater psy- (i.e. increased use of alcohol, tobacco and/or chological impact. drugs, altered work/life balance, increased fam- Due to the still lacking effective therapeutic ily/social conflictivity); (Wang et al., 2020b). remedies or vaccines guaranteeing protection to Moreover, imposed social distancing may cause COVID negative consequences, the WHO Joint or critically exacerbate existing loneliness and Mission on Coronavirus Disease 2019 has feeling alone is an independent risk factor for called for a worldwide response to draw on mood disorders and eventually, suicide (Hwang China’s extensive experience of non-pharma- et al., 2020). ceutical interventions (NPIs) aim to modify Despite the World Health Organization and behavior to reduce the spread of infectious dis- other public health authorities’ actions to con- eases (Brooks et al., 2020). In this sense, ini- tain the COVID-19 outbreak, at this time of cri- tially lockdown (social isolation or confinement) sis, one of the highest tolls paid is at a and quarantine have been one of the main meas- psychosocial level, testing the resilience and ures to stop the spread of infection and related adaptive resources of the population (World death toll. As happened in Wuhan, China, its Health Organization [WHO], 2020). Therefore, role has been crucial in heavily affected coun- to support mental and to favor psychosocial tries like Spain or Italy (Ni et al., 2020; well-being in different target groups during this Rodríguez-Rey et al., 2020). Quarantine differs crisis seems mandatory. We must consider also from lockdown since it entails the separation as a special group of interest vulnerable popula- and restriction of movement of people who tions, which include the economically disad- have potentially been exposed to a contagious vantaged or low-income individuals, racial and disease to ascertain if they become unwell, so ethnic minorities, the elderly, the children, the reducing the risk of them infecting others. homeless, those with human immunodeficiency COVID-19 social restriction measures efforts virus (HIV), and those with other chronic health have ranged from the mass quarantine of entire conditions, including severe mental illness. cities, confinement in government-run facili- Each of them might endure different and addi- ties, to self-isolation at home. There are prece- tional psychological impacts depending on their dents for such measures. In 2003, citywide characteristics and specific circumstances quarantines were also imposed in areas of China (Lurie, 1993; Wang et al., 2020a; Wu, 2020). Castellano-Tejedor et al. 3 The long-term psychosocial consequences are existence of a possible high risk profile of psy- the key challenge for our healthcare system, chological distress considering: demographics where the importance of mental health preven- (age, gender), degree and type of concerns about tion is not sufficiently recognized. Besides, it is the current COVID-19 pandemic, COVID-19 worth noting that most mental health services specific health data (i.e. close contact or suspi- were not active any longer in the midst of the cion of contact with the COVID-19 disease, outbreak (Marazziti et al., 2020) death of loved ones by COVID-19, diagnosis Previous research, mostly based on SARS, and/or hospital admission by COVID-19), self- Ebola and the H1N1 influenza found mixed perceived health status, and other environmental evidence concerning whether demographics conditions during the home confinement (i.e. and population’s general health status are pre- number of cohabitants, taking care of vulnerable dictors of the psychological impact of quaran- population). tine (Brooks et al., 2020). However, several main stressors directly related to higher malad- Methods justment and psychological impact have been outlined and appear related to COVID psycho- Design logical impact. These include socio-economic inequities conducting to lower access to sup- This study follows a cross-sectional population plies or reliable information, and caring for a survey design, with a descriptive-correlational frail loved one or being oneself in a high risk approach. health situation (Brooks et al., 2020). Similarly, recent surveys from the Census Bureau, the Participants Centers for Disease Control and Prevention, and preliminary data from cross-sectional stud- A sample of community-based adults were ies assessing COVID-19 psychological impact recruited for the study. Inclusion criteria have pointed out that COVID crisis has been required being ⩾18 years old. Exclusion crite- reported to be associated with rapid rises in ria were not understanding Spanish well enough psychological distress across many nations to complete the questionnaire. These criteria with female gender, the young, the less edu- were stated in the informed consent presented cated, those having lost their job during the before the survey. health crisis, and those presenting physical A total of 413 adults from different Spanish and psychological comorbidities, reporting provinces (Barcelona 82.57%, n = 341) filled greater mental health strain (Resnick, 2020; the survey. Socio-demographic characteristics Rodríguez-Rey et al., 2020). are comprehensively presented in Table 1. Most To the best of our knowledge, there is an respondents were women (70.05%), young urgent need to deepen our understanding on the adults (age M = 37.62 years, SD = 13.96; range psychological impact of the general population 18–73), with 9.2% (38/413) being older than living in Spain during the COVID-19 pandemic. 60 years old, married or cohabiting with a part- This novel information will serve as a first ner (54.70%) and children (35.80%) or with ground to develop psychological interventions, parents (mother: 34.10%, father: 25.40%). The so that the possible short and mid-long term and majority of the sample lived in the region of possible lasting psychological negative conse- Catalonia with just a few cases being abroad quences of the pandemic can be diminished or (0.73%, n = 3) at the moment of the study. reverted. Considering all this, this research has two main aims: (1) To explore and describe the Data collection mental health status and psychological impact of the general adult population in Spain during the Between 14th May and 2nd of June 2020 -in a COVID-19 confinement, and (2) to examine the context of strict general population lockdown 4 Journal of Health Psychology 00(0) Table 1. Participants’ demographics (N = 413). margin of error and a confidence level of 95%, a minimum sample size of 384 was estimated to Variables n (%) be sufficient to reveal differences in an average Gender response to each survey question. Male 121 (29.30%) Female 291 (70.50%) Prefer not to label 1 (0.20%) Outcomes and covariables Country of origin Based on previous research and the unavailabil- Spain 410 (99.27%) ity of a reliable and validated questionnaire to Other 3 (0.73%) explore COVID-19 related psychosocial impact Cohabiting and distress, an ad hoc 34-item online survey Yes 386 (93.46%) was designed. No 27 (6.54%) Participants provided information regarding Age their gender, age, residency, marital status, 18–35 192 (46.49%) number of children, number of people living 36–59 183 (44.31%) >60 38 (9.20%) together and dependent cohabitants during the Occupation home confinement. Healthcare professionals 98 (23.73%) COVID-related distress and degree of con- Non-healthcare professionals 315 (76.27%) cern was asked by means of a numeric scale ranging from 0 to 10 (not all distressed/con- cerned, to very distressed/concerned). Main that started on 16th March-, a brief snowball worries were also collected by multiple choice survey entitled: “How am I coping with the sit- and one open question to specify in case of not uation that COVID-19 has generated?” was dis- finding relevant categories to express their main tributed via mailing lists and social media worries related to COVID-19. Psychological (Whatsapp). Participants were encouraged to symptoms were also screened in a multiple distribute the survey. We selected an online sur- choice item collecting aspects such as anxiety, vey as the lockdown and enrollment of partici- stress, depressive symptoms, panic attacks, pants precluded in-person surveys and random fatigue, anhedonia, loss of interest in social selection. We deployed an ad hoc multifactorial contact, disturbances in eating or sleep patterns, 34-item questionnaire using the Kwik surveys irritability, intense fear, frequent and invasive platform. A brief advertisement explaining the concerns, general discomfort or other psycho- research objectives, usefulness of results and logical symptoms. outlining main ethical and privacy details Respondents were asked to declare if they accompanied the survey link in both different have received psychological support during the distribution channels. The survey was available confinement and, in affirmative cases, if it was only in Spanish, as we aimed to reach as many due to COVID-19 situation, due to pre-existing respondents as possible in our country. We psychological problems, or both. They were made the length of the survey short enough to also asked to state if they believe they would not take more than 5 minutes to ensure a high need psychological support in a near future due completion rate. To compensate for the brevity to the experience (main outcome variable). of the survey, we included 4 open-answer boxes COVID-related data were also collected. to specify some responses and 1 open-answer Participants indicated whether they have been question asking respondents to offer more diagnosed of COVID-19, type of diagnostic test details concerning the topic assessed. (rapid strep test, CRP or swab, if applicable), Sample size calculation was based on a mar- need for hospital admission (including ICU) gin of error and confidence level rather than and symptoms consistent with a diagnosis of prevalence or expected effect sizes. With a 5% COVID (fever, cough, sore throat, headaches, Castellano-Tejedor et al. 5 muscle or joint pain, dizziness, diarrhea, rhini- test was used to determine whether parametric or tis, chills and respiratory distress) that they non-parametric tests were indicated. Bivariate have experienced in the last two weeks. comparisons were performed through either t Participants were also asked about the degree to Student test and ANOVA for variables with more which they considered they could have been than two categories or levels, the Mann-Whitney infected by COVID without knowing, or in U test for continuous variables or Chi-square test close contact with people infected by COVID, (and Fisher's exact test when n < 5) for dichoto- if they have experienced the loss of a loved one mous variables. The correlation of two variables due to COVID-19, and the degree of confidence was compared using Pearson correlation. To ana- in healthcare professionals to both, diagnosed lyze the predictors of psychological impact as COVID by just clinical criteria (history of the main outcome variable, contingency tables symptoms) and by means of objective testing. were performed with the Chi-Square test. General self-perceived health status (based Subsequently, a binary logistic regression analy- on item 1 from SF122: very good, good, regular, sis (forward stepwise conditional method) was bad, very bad) and history of relevant health performed with those variables that exhibited a conditions were collected too. statistically significant relationship with the Finally, an open question was offered to add main variable (need for psychological support in any other relevant aspects they consider not the future; yes vs. no), giving results as adjusted being included or requested in the survey. odds ratios (Exp (B)). This main outcome varia- ble to describe the psychological burden of the COVID-19 pandemic and to determine high risk Ethics profiles, was measured using scores on item 29 Research ethics procedures of this study com- of the survey, aimed at assessing need for psy- plied with European and national legislation chological support in a near future due to (e.g. the Charter of Fundamental Rights of the COVID-19 health crises. The level of statistical EU, Directive 95/46/EC of the European significance was 5% (p ⩽ 0.05). In all cases, Parliament and of the Council of 24 October appropriate post hoc analyses were performed, 1995 on the protection of individuals with and 95% confidence intervals were reported. All regard to the processing of personal data and on statistical analyses were performed using the the free movement of such data). All data was SPSS version 25 (IBM Corp.). collected and kept with all guarantees of confi- dentiality and codification procedures were employed to ensure the privacy and confidenti- Data sharing statement ality of information. All participants were The current article includes the complete raw informed about study purposes and direct data-set collected in the study including the par- informed consent was requested to all respond- ticipants’ data set, syntax file, and log files for ents before sending their responses. Data were analysis. Pending acceptance for publication, kept confidential and were not disclosed unless all of the data files will be automatically for study purposes. uploaded to the Figshare repository. Statistical analysis Results Descriptive statistics were calculated for all The psychological and physical baseline and final outcome variables using meas- ures of central tendency (mean, standard devia- impact of COVID-19 tion, range for continuous variables; frequencies Concerns and psychological symptoms. During and total percentages for categorical variables). confinement, most people reported concerns For bivariate analysis, Kolmogorov-Smirnov about different aspects (average worries per 6 Journal of Health Psychology 00(0) Figure 1. Main worries in different age groups. Table 2. Worries expressed by each gender. Main worries (affirmative responses Times reported Women n = 291 Men n = 121 are presented) (n = 413) n (%)≀ n (%)≀≀ n (%)≀≀ χ2 p My health / Getting infected 104 (25.18%) 69 (23.71%) 35 (28.93%) 1.231 0.267 Be a carrier and infect others 145 (35.11%) 103 (35.40%) 42 (34.71%) 0.018 0.895 Health status of loved ones 303 (73.36%) 215 (73.88%) 88 (72.73%) 0.059 0.809 Work concerns 75 (18.16%) 56 (19.24%) 19 (15.70%) 0.720 0.396 Own economy 79 (19.13%) 55 (18.90%) 24 (19.83%) 0.048 0.826 Economy of society 133 (32.20%) 95 (32.65%) 38 (31.40%) 0.060 0.806 Social revolts 15 (3.63%) 11 (3.78%) 4 (3.31%) 0.055 1.000 Not recovering previous normality 120 (29.05%) 90 (30.93%) 30 (24.79%) 1.558 0.212 (social & leisure life) Uncertainty about the future 166 (40.19%) 127 (43.64%) 39 (32.23%) 4.626 0.031* New coronavirus outbreaks 123 (29.78%) 88 (30.24%) 35 (28.93%) 0.071 0.791 Other worries (not specified in the list) 24 (5.81%) 17 (5.84%) 7 (5.79%) 0.001 0.982 No worries 4 (0.97%) 2 (0.69%) 2 (1.65%) 0.892 0.584 *Statistical significant differences between genders according to the Chi squared test. ≀Number of times (%) reporting this concern on the survey. ≀≀Number of times (%) reporting this concern in the gender sub-sample. person = 3.12, SD = 1.05, range 0–9, >5 con- For the whole sample, the degree of concern cerns n = 16). Main worries for different age was medium-to-high (M = 7.01, SD = 1.89, range groups are displayed in Figure 1. Table 2 shows 0–10, 17.19% scoring ⩾9) without significant main concerns according to each gender. differences between genders, while the degree of emotional distress was medium (M = 5.61, Castellano-Tejedor et al. 7 SD = 2.44, range 0–10, 6.30% scoring ⩾9) with 0.002). The latter, also related to those concerned women reporting greatest emotional distress about the economy of society ( χ 2 (1, N = 413) = (t(410) = 2.858, p = 0.004, 95%CI [0.234, 1.264]). 6.21, p = 0.013). Finally, being worried about Older participants were more concerned about not being able to regain normality was associ- ated with stress ( χ (1, N = 413) = 6.88, p = 2 their own health when compared to younger adults (t(411) = −5.642, p < 0.001, 95%CI 0.009), depressed mood ( χ 2 (1, N = 413) = 7.833, [−11.611, −5.611]). When asking about how p = 0.005) and apathy ( χ 2 (1, N = 413) = 11.01, much they care about being a carrier of COVID- p = 0.001). 19 and transmitting the virus to others, mean Additionally, the number of psychological scores were also medium-to-high (M = 7.81, symptoms experienced correlated positively SD = 2.03, range 0–10, 39.47% scoring ⩾9) with the degree of concern (r = 0.245, p < 0.001), independently of gender, but with the oldest number of expressed concerns (r = 0.216, p < being significantly the most concerned about 0.001), emotional distress (r = 0.453, p < 0.001), this risk (r = 0.103, p = 0.036). the specific concern about being a carrier of Almost one third of the sample (23.73%, COVID-19 and transmitting the virus to others n = 98) work in healthcare settings. These pro- (r =0.128, p = 0.009), number of physical symp- fessionals were significantly more concerned toms endured during confinement (r = 0.397, compared to general population about infecting p < 0.001), considering relevant to offer sup- others ( χ 2 (1, N = 413) = 9.31, p = 0.002) and port to those affected by COVID-19 (r = 0.184, the uncertainty about the future ( χ 2 (1, N = 413) p < 0.001) and to healthcare professionals = 3.92, p = 0.048). Similarly, they were very (r = 0.145, p = 0.003), and the probability of ask sensitized of the higher odds of being infected for psychological support in the future (t(146) = −3.315, p = 0.001, 95%CI [−1.467, (r = 0.425, p < 0.001). −0.371]). In the last 14 days, most referred psychologi- Self-perceived risk and confidence in healthcare cal symptoms were apathy (n = 202, 48.91%), system. For the whole sample, self-perceived depressed mood (n = 183, 44.31%), fatigue (n = risk of being infected was medium (M = 5.08, 177, 42.86%), stress (n = 169, 40.92%) and anx- SD = 2.26, range 0–10, 34.87% scoring ⩽4) and iety (n = 165, 39.95%), with women (t(410) = self-perceived severity of possible conse- 3.292, p = 0.001, 95%CI [0.403, 1.599]) and the quences of being infected was also medium-to- youngest respondents (r = −0.369, p < 0.001), low (M = 4.77, SD = 2.47, range 0–10, 42.37% those reporting a greater number of symptoms. scoring ⩽4). Similarly, only a few individuals All these psychological symptoms revealed believe that, with high probability (scoring 8 in different associations with expressed con- a 0–10 probability scale) they might have been cerns. First, concerns about one’s health was positive for COVID (n = 49, 11.86%). A similar related to greater general physical discomfort proportion of subjects were doubtful (n = 76, ( χ 2 (1, N = 413) = 4.34, p = 0.037), while con- 18.40%) while most of the sample reported that cern about being a carrier and infecting others they did not believe they had been infected was associated with anxiety ( χ 2 (1, N = 413) (n = 238, 57.63%, scoring <5). = 7.57, p = 0.006). Secondly, a higher degree of A total of 47 individuals (11.38%) confirmed concern about one's own work situation was to have maintained close contact with people related to depressed mood ( χ 2 (1, N = 413) = positive for COVID at less than 2 m, and 35 3.98, p = 0.046) and apathy ( χ 2 (1, N = 413) = individuals (8.47%) expressed being suspicious 4.51, p = 0.034), while concern about one's own of having maintained close contact with people economy was related to anxiety ( χ 2 (1, N = 413) probably positive for COVID. Those having had = 4.65, p = 0.031), little desire to talk or contact direct contact with a person infected with friends ( χ 2 (1, N = 413) = 6.71, p = 0.010) and COVID-19 were more prone to consider them- intrusive worries ( χ 2 (1, N = 413) = 9.71, p = selves at risk (t(53.64) = −3.616, p = 0.001, 8 Journal of Health Psychology 00(0) 95%CI [−2.315, −0.663]) or even to have been conditions being the most prevalent asthma already infected without knowing (t(63.33) = (n = 13), hypertension (n = 9) and allergies −3.386, p = 0.001, 95%CI [−2.893, −0.741]). (n = 7). Similarly, those considering that they might Self-perceived health for the whole sample have been in contact with a possible COVID-19 was “good” (n = 224, 54.24%) with the oldest positive individual, were also more prone to (t(173.96) = −2.145, p = 0.033, 95%CI [−6.726, consider that they might have been infected for −0.279]), those suffering from chronic condi- the virus (t(411) = −3.442, p = 0.001, 95%CI tions ( χ 2 (1, N = 413) = 9.809, p = 0.002) and [−2.694, −0.735]) and will probable ask for psy- those who received psychological support dur- chological support in the future (t(411) = −2.140, ing the pandemic ( χ 2 (1, N = 413) = 5.415, p = p = 0.033, 95%CI [−1.959, −0.083]). 0.020) reporting worse scores. Confidence in healthcare professionals to Health-care professionals reported better detect COVID-19 from its symptoms (without self-perceived health than non-healthcare pro- using tests) was medium (M = 6.42, SD = 2.42) fessionals ( χ 2 (1, N = 413) = 8.13, p = 0.004) and negatively associated with the number of and also, reported less number of physical psychological symptoms experienced (r = symptoms (t(193.8) = 2.009, p = 0.046, 95%IC −0.123, p = 0.012). This confidence increased [0.011, 1.179]) and some psychological distur- when the diagnosis of the infection was made bances such as apathy ( χ 2 (1, N = 413) = 6.34, p = 0.011) and changes in appetite ( χ (1, N = 413) 2 by using tests (i.e. rapid strep tests, CRP or swab) (M = 8.16, SD = 1.77). Only a few cases = 5.74, p = 0.017). (3.60%, n = 15) admitted being tested for For the whole sample, general self-perceived COVID with positive results obtaining this health was inversely related to degree of con- diagnosis in older participants (U = 2087.50, cern (t(411) = 3.186, p = 0.002, 95%CI [0.255, p = 0.048), by means of a CRP test (n = 11, 1.077]), emotional distress (t(411) = 4.553, p < 73.33%), a quick test (n = 3, 20%) or a swab 0.001, 95%CI [0.689, 1.735]), self-perceived (n = 1, 6.67%). Any of the respondents required severity of COVID-19 in case of being infected ICU admission due to COVID-19 during the (t(411) = 2.931, p = 0.004, 95%CI [0.264, 1.340]), confinement. However, 20% (n = 3) of the indi- degree of concern about being a carrier of the viduals diagnosed of COVID-19 had to be virus and infecting others (t(411) = 2.512, admitted to a hospital ward and 60% (n = 9) p = 0.012, 95%CI [0.123, 1.007]), number of were quarantined. psychological symptoms endured in the last 14 days (t(160.2) = 7.268, p < 0.001, 95%CI Health status and COVID-related physical symp- [1.734, 3.028]), physical symptoms related to toms. Despite this low prevalence of diagnosed COVID-19 (t(124.4) = 6.130, <0.001, 95%CI individuals, within the immediate period before [0.654, 1.277]) and probability of needing psy- the study (two weeks), some of the participants chological support in the future (t(411) = 4.375, had experienced a wide range of symptoms p < 0.001, 95%CI [0.714, 1.879]). that have been associated with COVID-19 (see Figure 2). Globally, the most self-reported COVID-19 consequences. A little but relevant physical symptoms were headache (n = 123, percentage of the sample (12.59%, n = 52) expe- 29.78%), muscular and joint pain (n = 90, rienced the loss of a family member or a close 21.79%) and sore throat (n = 49, 11.86%). It is contact, which was related to greater degree important to note that half of the sample (52.30%, of concern (t(411) = −2.224, p = 0.027, 95%CI n = 216) indicated that they had not experienced [−1.171, −0.072]), risk of being infected symptoms within the same time period. (t(411) = −2.077, p = 0.038, 95%CI [−1.353, A sizable proportion of participants (n = 70, −0.037]), self-perceived severity in case of 16.95%) affirmed to suffer from chronic being infected (t(411) = −2.664, p = 0.008, Castellano-Tejedor et al. 9 Figure 2. COVID-19 related symptoms experienced in different age groups. 95%CI [−1.686, −0.254]), degree of concern of healthcare professionals working at front line being a carrier and transmitting the virus (M = 9.20, SD = 1.28, range 2–10, 77.48% scor- (t(88.87) = −3.461, p = 0.001, 95%CI [−1.202, ing ⩾9). Women turned out to be the most sen- −0.325]) and older age (t(411) = 3.291, p = 0.001, sitized to this situation, showing greater 95%CI [10.755, 2.711]). Specifically, 31 indi- importance of offering this type of support for viduals reported the loss of a relative (n = 6 first both groups, general (t(175.61) = 3.936, p < degree relative, n = 5 second degree, n = 14 third 0.001, 95%CI [0.337, 1.014]) and healthcare degree, n = 6 fourth degree) and 24 the loss of professionals (t(172.02) = 3.546, p = 0.001, 95%CI acquaintances and friends. Among those report- [0.246, 0.865]), respectively. Similarly, they ing the loss of a close one, 30.77% were unsure were the most likely to express the need for psy- about the nature of the loss, not relating it chological support in the future (t(410) = 4.238, directly to COVID. p < 0.001, 95%CI [0.654, 1.786]). Globally, the A small percentage of the studied sample willingness or intention to ask for psychologi- (9.20%, n = 38) revealed having received psy- cal support in the future was directly related to chological support during the confinement uncertainty about the future experienced during period and just a minority of them (10.53%, confinement (t(411) = −3.049, p = 0.002, 95%CI n = 4) affirmed that this was related to the [−1.351, −0.292]). COVID situation. When asking about the importance of providing psychological support High risk profile of psychological impact as a to face the health crises caused by COVID, response to the COVID pandemic. A statistically mean score for those affected and their families significant model (χ2(7,N = 411) = 100.112; were high (M = 8.92, SD = 1.43, range 2–10, p < 0.001;Nagelkerke R2 = 0.308) predicting 66.83% scoring ⩾9) and especially, for profiles of higher odds to experience persistent 10 Journal of Health Psychology 00(0) psychological was obtained for the studied vary from immediate effects - like irritability, sample, including the following factors: higher fear of contracting and spreading infection to degree of distress (OR = 208, p < 0.001, 95%CI family members, anger, confusion, frustration, [1.089, 1.341]), reporting higher number of loneliness, denial, anxiety, depression, insom- psychological symptoms during confinement nia, despair to extremes of consequences, (OR = 1.208, p < .001, 95%CI [1.089, 1.341]), including suicide (Barbisch et al., 2015; Brooks suffering from chronic conditions (OR = 2.541, et al., 2020; Liu et al., 2012). p = 0.006, 95%CI [1.313, 4.917], concerned Another very relevant aspect to be consider about the uncertainty in the future (OR = 1.743, is fear, stigma and societal rejection regarding p = 0.027, 95%CI [1.065, 2.853), receiving psy- the quarantined cordon in forms of discrimina- chological support during confinement (OR = tion, suspicion and avoidance by neighborhood, 6.236, p < 0.001, 95%CI [2.736, 14.214]), being workplace prejudice (i.e. among healthcare pro- female (OR = 0.545, p = 0.033, 95%CI [.312, fessionals quarantined) and withdrawal from .952]) and younger (OR = 0.975, p = 0.019, social events even after containment of epidem- 95%CI [0.955, 0.996]). ics (Barbisch et al., 2015; Brooks et al., 2020; Liu et al., 2012); (Mertens et al., n.d.). In this sense, in our sample, health professionals were Discussion clearly more aware than the general population The COVID-19 has led to dramatic changes about the possibility of becoming transmitters worldwide in people’s everyday lives. To com- of the virus, despite not being the subgroup that bat the pandemic, many governments have was worse off both physically and mentally. implemented social distancing, quarantine, and Nevertheless, their concern was also greater stay-at-home orders. Despite the urgent need regarding the uncertainties of the future in rela- claimed by several authors to systematically tion to the evolution of this pandemic. Despite examine the psychological health of the popula- positive general health status among this popu- tion being most affected by the COVID-19 pan- lation, healthcare professionals who are (or sus- demic (Brooks et al., 2020; de Carvalho et al., pected to be) infected with COVID-19 and need 2020; Duan and Zhu, 2020; Zandifar and isolation or quarantine might require special Badrfam, 2020), there is still limited scientific attention to meet their fear, anxiety and other data on the impact of such extreme and extraor- psychological effects (Ruiz and Gibson, 2020; dinary measures on mental health. To fill this Sankhi and Marasine, 2020; Tan et al., 2020). gap in the literature, this online population sur- Half of the sample rates their self-perceived vey study focused on exploring and describing health as good despite the health crises. This data on the psychological impact that the first could be explained because also, half of the stages of COVID-19 crisis and confinement sample did not report any symptoms compati- had on Spaniards’ psychological health. ble with a COVID-19 diagnosis. However, and Concerning the first objective of the study as expected, health status was significantly aimed at describing psychological impact, it has related to mental health, including COVID- been found that main worries during confine- related distress and concerns, the specific worry ment in the studied sample were the health sta- of being a possible case and infecting others, tus of the loved ones, uncertainty about the and the expectancy of asking for psychological future and being a carrier and infecting others. support in a near future. Likewise, despite being There were no significant differences between a clear minority in our sample (<10% of the genders or age. Nevertheless, the older reported whole sample), people receiving psychological to be equally worried about being infected and support -related or not to COVID-, showed the economy of the society. Our results are in poorer self-perceived health, maybe due to a line with previous research that has outlined greater acceptance and/or insight about their that the psychological impact of quarantine can suffering and general health. Often, therapeutic Castellano-Tejedor et al. 11 change involves a transition period in which, also those significantly more aware of the need through work with the elements that cause dis- of this service to cope with the situation and comfort, painful aspects of the individual are promote resilience among those affected. This revealed and might temporarily decrease his/ is in line with previous research depicting gen- her well-being, to later give way to a level of der differences in preferences for psychologi- superior performance. This is why sometimes cal treatment and triggers to help-seeking the initiation and development of psychological (Liddon et al., 2018). therapy can translate into higher levels of emo- As for age, some literature in the field of dis- tional distress than those experienced by people aster and trauma indicates that the elderly are who do not come into contact with this inner particularly vulnerable to the negative psycho- reality (Corey, 2008; Goldfried, 1980). In this logical sequelae of critical situations, such as study, people having received a positive diag- PTSD (Ngo, 2001). However, in line with our nosis for COVID-19 claimed to be more predis- results, most of the studies have found that age posed to seek psychological help in the near constitutes a protective effect (Jorm, 2000; future, possibly related to fear experienced and/ Website, n.d.) that in our case had a medium or uncertainty about the future. effect size and the youngest have revealed as When analyzing variables related to psycho- the collective more vulnerable to suffer more logical impact of COVID-19, it was found that, psychological symptoms (e.g. apathy, depressed in accordance with other studies carried out in mood, tiredness/fatigue, stress or irritability) China (Liu et al., 2020a; Sun et al., 2020; Wang (Mazza et al., 2020; Qiu et al., 2020). Contrary et al., 2020a; Wu, 2020), or other countries to what many of the messages that the media (Alkhamees et al., 2020; Varshney et al., 2020), have shared throughout the COVID crisis, espe- our results suggest that women and vulnerable cially in periods of post-lockdown or de-escala- populations such as the youngest and the tion (El alegato de los mayores a los jóvenes elderly, are the ones that suffered the greater que pasan del coronavirus: “Se acabó la fiesta,” psychological impact due to different factors. 2020) (La OMS alerta a los jóvenes sobre el Concerning gender, the study of Rodríguez riesgo del ocio noct. . . - Consalud, 2020), and collaborators (Ni et al., 2020; Rodríguez- young adults have turned out to be the most Rey et al., 2020), carried out in our own coun- concerned group about being a possible carrier try, has already shown that it is women who and transmitter of the virus. This might be experience the highest levels of discomfort, explained because they are the ones who have given all the stresses imposed by the COVID had to go to work forcibly during confinement, pandemic situation. This result should not or because they could be more aware of not come as a surprise if we consider the ways that having maintained strict social isolation and gender roles differently affect women and men distancing, for whatever reason. In any case, (Wenham et al., 2020). Likewise, in our cul- future studies should explore the psychological tural setting, women present a more external- impact of the COVID-19 pandemic in larger izing pattern and are more open to sharing samples of both age-groups, analyzing how their emotional distress compared to men younger and older participants cope and recover (Chaplin, 2015). However, results in this area differently from the psychological effects of the are inconsistent and recent evidence shows COVID-19 crisis. What is clear from our results that there are many nuances, especially with is that the elderly are those with the greatest regard to non-verbal communication of emo- probability of suffering from chronic diseases tions (McDuff et al., 2017). Despite the whole and experiencing physical symptoms compati- sample considered crucial to offer psychologi- ble with a COVID diagnosis and, perhaps for cal support to any individual significantly this reason, they are the ones that have been affected by the virus or its consequences (spe- preferably tested for COVID in our country. It cially, healthcare professionals), women were is important to bear in mind that during the time 12 Journal of Health Psychology 00(0) of execution of this survey, massive tests were gender or cohabiting still need to be further not being carried out in our country. This has studied since mixed evidences have been been largely due to lack of resources and/or reported (Vindegaard and Benros, 2020). poor planning. Therefore, and as our results have shown, there was a lot of uncertainty regarding the possibility of being infected or Implications not, or having been in contact with other infected people, with the consequent chain of Getting people safe through the pandemic is the transmission of contagions that this could entail immediate aim. Subsequently, a major effort and in the population. Thus, only 15 cases were targeted resources will be necessary to ensure tested and resulted positive for COVID-19 in services that will allow people to maintain or our sample. They were precisely those older return to optimal functioning are quickly re- and reporting the worst self-perceived health. established (Milligan and McGuinness, 2009). So far, not only physical but also psycho- Some of the issues that have been revealed as logical mid and long-term effects of COVID-19 major concerns following quarantine are fears are still quite unknown to the scientific com- about becoming infected and then infecting oth- munity. In a study examining the level of stress ers. The health status of loved ones and uncer- and distress one year after the outbreak among tainty about the future and possible new survivors (general population) of SARS, it was outbreaks are very prevalent in the studied sam- found that they still showed high levels of stress ple. These stressors are likely to cause high lev- and worrying levels of psychological distress; els of emotional distress and thus, worsen the recognising the importance of not ignoring the psycho-affective state and the self-perceived long-term psychological implications of the health status of people (Perini, 2012; Wang et al., infectious diseases, mainly in healthcare pro- 2020b). Information and communication tech- fessionals, specifying that mental health ser- nologies could mitigate the mental health impact vices could play an important role in the of COVID-19 and lockdowns by maintaining psychosocial rehabilitation (Brooks et al., 2020; social contact during physical distancing, as well Lee et al., 2007). In the current pandemic, a as providing health services including: informa- recent study in this line carried out in China, tion provision, telemedicine and/or online psy- revealed that 54% of respondents showed mod- chological counseling (Liu et al., 2020b; Wang erate-to-severe persistent psychological impact, et al., n.d.). Yet, it is also important to bear in 16% and 29% moderate-to-high depressive or mind that social and mass media can also spread anxiety symptoms, respectively, and 8% mod- fake news during an epidemic that might cause erate-to-high levels of stress (Wang et al., negative emotions and worsen the psychological 2020b). Besides, anxiety and depression symp- impact (Grady et al., n.d.; Kadam and Atre, 2020; toms showed no decline four weeks after the Kramer et al., 2014). During the COVID-19 cri- COVID-19 pandemic (Wang et al., 2020a). sis, digital technologies have become a major Finally, our results have revealed that the route for accessing remote care. Therefore, the risk profile to suffer greater psychological need to ensure that these tools are safe and effec- impact and needing psychological support in tive has never been greater (Inkster et al., 2020). the future as a consequence, are younger Ecological Momentary Assessments (EMA) are females worried about the future, experiencing a great opportunity in this context, to provide higher degree of distress, psychological symp- information and assessment at real time and in toms, already following psychological therapy the real context, improving the ecological valid- and suffering from pre-existing chronic condi- ity of assessment tools. In addition, because of tions. These results are in line with recent the enormous advances in information and com- research (Barbisch et al., 2015; Brooks et al., munication technologies (ICTs), nowadays it is 2020; Liu et al., 2012) but some factors such as possible to conduct tailored person-centered Castellano-Tejedor et al. 13 interventions in natural contexts, which can the number of respondents who have been quar- facilitate efficiency and efficacy and also, timely antined and tested for COVID-19, and had a application and generalization of learned skills. contact history with infected persons was mini- These types of interventions, also known as mal, and our result could not be generalized to Ecological Momentary Interventions (EMIs) are them. Despite all the above limitations, our beginning to be used more and more in the field study provides very relevant information about of health psychology with promising results the immediate psychological responses of the (Heron and Smyth, 2010; Moskowitz and Young, general population on the COVID-19 pan- 2006; Versluis et al., 2016). In this sense, Zhang demic, giving a clear idea about the magnitude et al. (2020) put forward a new psychological of the psychological burden on the community crisis intervention model by utilizing internet during the COVID-19 outbreak. Besides, results technology. This new model integrates physi- cover many factors that can influence mental cians, mental health professionals and social health, providing a broader vision of the issue workers into Internet platforms to carry out psy- for future research, aimed at minimizing the chological intervention to patients, their families psychological impact of similar health crises. and medical staff. This is one very valuable model that could serve as a basis for developing Conclusions a similar comprehensive psychological crisis intervention response system that is applicable During this time of global pandemic, it is so for urgent social and psychological problems, important to continue to advocate for those in such as this caused by the COVID-19 the community who are particularly vulnerable pandemic. in the context of considerable existing mental health and associated social challenges. Policy makers need to include specific sections on dif- Limitations ferent COVID-19 management protocols, This study has its limitations owing to a small addressing how to handle the psychological sample size for exploratory factor analysis and impact of the pandemic on mental health, both for the time-sensitivity of the outbreak and with by the virus itself and the emerging social situ- a curfew in place, we adopted a snowballing ation. Special emphasis should be placed on sampling strategy, which allows for studies to health professionals who are one of the most take place where otherwise it might be impos- vulnerable groups to suffer psychological disor- sible to conduct because of a lack of partici- ders, along with hospitalized patients and peo- pants. However, non-probabilistic sampling ple with pre-existing mental health conditions. techniques make impossible to determine the Considering that we are still in the midst of an sampling error or make solid inferences about evolving situation that can unleash a deeper populations. Also, the survey provides only a kind of unmoored experience of people’s life, snapshot of psychological responses at a par- we believe our results provide new insights on ticular point in time, and therefore, a longitudi- the psychological impact of COVID-19, and nal study with larger sample size is required to can help to design tailored person-centered provide information on whether the observed interventions for those at higher risk, helping impact will last for longer periods. Similarly, not only to adjust but also to thrive through the self-reported psychological impact might not unknown times ahead. adequately represent the mental health status assessed by means of a full in depth clinical interview; thus, for the outcome to be deter- Highlights mined, prospective studies are necessary to pro- •• The transformation that coronavirus dis- vide more accurate data to support the need for ease pandemic has brought upon the focused public mental health strategies. Lastly, world and mental health is unparalleled. 14 Journal of Health Psychology 00(0) •• Online-based surveys have revealed as COVID-19 pandemic on the general popu- suitable methods for gathering data on psy- lation of Saudi Arabia. Comprehensive chological impact during confinement. Psychiatry 102: 152192. DOI: 10.1016/j. •• It is crucial to leverage technologies for comppsych.2020.152192. Barbisch D, Koenig KL and Shih F-Y (2015) Is there the most vulnerable, especially in extraor- a case for quarantine? Perspectives from SARS dinary situations such as confinement. to Ebola. Disaster Medicine and Public Health •• Ecological Momentary Assessments/ Preparedness 9(5): 547–553. DOI: 10.1017/ Interventions are a great opportunity in dmp.2015.38. these contexts of lockdown and quarantine. Brooks SK, Webster RK, Smith LE, et al. (2020) The psychological impact of quarantine and how to Acknowledgements reduce it: Rapid review of the evidence. The We gratefully acknowledge all participants for their Lancet 395(10227): 912–920. DOI: 10.1016/ contributions to the study and for circulating this sur- s0140-6736(20)30460-8. vey during the process of data collection. Chaplin TM (2015) Gender and emotion expres- sion: A developmental contextual perspective. Emotion Review: Journal of the International Authors’ contributions Society for Research on Emotion 7(1): 14–21. CCT and AC were responsible for the study design DOI: 10.1177/1754073914544408. and conducting. MTS and CCT analyzed data. CCT Corey G (2008) Theory and Practice of Counseling wrote the first draft of the manuscript. CCT, MTS, and Psychotherapy. Cengage Learning. Available and AC participated in the following versions of the at: http://perpus.univpancasila.ac.id/repository/ manuscript and made important contributions to its EBUPT190498.pdf final version. All authors have read and have El alegato de los mayores a los jóvenes que pasan approved the final manuscript. del coronavirus: “Se acabó la fiesta” (2020). Available at: https://www.lavanguardia.com/ Declaration of conflicting interests participacion/debates/20200802/482622885805/ debate-mayores-jovenes-contagios-rebrotes- The author(s) declared no potential conflicts of inter- covid-19-ocio-nocturno.html (accessed 26 August est with respect to the research, authorship, and/or 2020). publication of this article. Goldfried MR (1980) Toward the delinea- tion of therapeutic change principles. The Funding American psychologist 35(11): 991–999. DOI: The author(s) received no financial support for the 10.1037//0003-066x.35.11.991. research, authorship, and/or publication of this Grady C, Feliciano JT, Kwon J, et al. (n.d.) Influence article. of news media and public health agencies dur- ing pre-pandemic COVID-19: Twitter analysis (Preprint). Avaialble at: https://preprints.jmir. 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