STUDY PROTOCOL published: 02 July 2021 doi: 10.3389/fpsyt.2021.642763 Study Protocol—Coping With the Pandemics: What Works Best to Reduce Anxiety and Depressive Symptoms Lydia Fortea 1,2,3† , Aleix Solanes 1,4† , Edith Pomarol-Clotet 2,5 , Maria Angeles Garcia-Leon 5 , Adriana Fortea 6,7 , Carla Torrent 2,8,9 , Cristina Varo 2,3,8,9 , C. Mar Bonnin 2,3,8,9 , Laura Montejo 2,3,8,9 , Jordi Alonso 10,11,12 , Susana Carmona 2,13,14 , Pau Soldevila-Matías 15 , Irene Alustiza 16,17 , Daniel Arbós 18 , Diego Hidalgo-Mazzei 2,3,8,9 , Iria Grande 2,3,8,9 , Eduard Vieta 2,3,8,9 , Miquel Àngel Fullana 1,2,8 and Joaquim Radua 1,2,19,20* 1 Imaging of Mood- and Anxiety-Related Disorders (IMARD) Group, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain, 2 Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain, 3 Department of Medicine, University of Barcelona, Barcelona, Spain, 4 Department of Psychiatry and Forensic Medicine, Autonomous University of Barcelona, Barcelona, Spain, 5 FIDMAG Research Foundation, Barcelona, Edited by: Spain, 6 Multimodal Neuroimaging in High Risk and Early Psychosis, Institut d’Investigacions Biomèdiques August Pi i Sunyer Daniel Bressington, (IDIBAPS), Barcelona, Spain, 7 Department of Child and Adolescent Psychiatry, Institute of Neurosciences, Hospital Clínic de Charles Darwin University, Australia Barcelona, Barcelona, Spain, 8 Adult Psychiatry and Psychology Department, Institute of Neurosciences, Hospital Clínic de Reviewed by: Barcelona, Barcelona, Spain, 9 Bipolar and Depressive Disorders, Institut d’Investigacions Biomèdiques August Pi i Sunyer Lucia Romo, (IDIBAPS), Barcelona, Spain, 10 Health Services Research Unit, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Université Paris Nanterre, France Barcelona, Spain, 11 Department of Experimental and Health Sciences, Universitat Pompeu Fabra (UPF), Barcelona, Spain, 12 Md. Saiful Islam, Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Jahangirnagar University, Bangladesh Madrid, Spain, 13 Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain, 14 Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Getafe, Spain, 15 Department of Basic Psychology, Faculty of *Correspondence: Psychology, University of Valencia, Valencia, Spain, 16 Department of Psychiatry and Clinical Psychology, Clínica Universidad Joaquim Radua de Navarra, Pamplona, Spain, 17 Instituto de Investigación Sanitaria de Navarra (IDISNA), Navarra, Spain, 18 Communication radua@clinic.cat Office, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain, 19 Early Psychosis: Interventions † These and Clinical-Detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, authors share first authorship King’s College London, London, United Kingdom, 20 Centre for Psychiatric Research and Education, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Specialty section: This article was submitted to Public Mental Health, Background: The coronavirus disease 2019 (COVID-19) pandemic and lockdown a section of the journal might increase anxiety and depressive symptoms in most individuals. Health bodies Frontiers in Psychiatry recommend several coping behaviors to protect against such symptoms, but evidence Received: 16 December 2020 Accepted: 26 May 2021 on the relationship between these behaviors and symptoms mostly comes from Published: 02 July 2021 cross-sectional studies in convenience samples. We will conduct a prospective Citation: longitudinal study of the associations between coping behaviors and subsequent anxiety Fortea L, Solanes A, Pomarol-Clotet E, Garcia-Leon MA, Fortea A, Torrent C, and depressive symptoms during the COVID-19 pandemic in a representative sample of Varo C, Bonnin CM, Montejo L, the Spanish general adult population. Alonso J, Carmona S, Soldevila-Matías P, Alustiza I, Arbós D, Methods: We will recruit 1,000 adult participants from all autonomous communities of Hidalgo-Mazzei D, Grande I, Vieta E, Spain and with sex, age, and urbanicity distributions similar to those of their populations Fullana MA and Radua J (2021) Study Protocol—Coping With the and assess anxiety and depressive symptoms and coping behaviors using fortnightly Pandemics: What Works Best to questionnaires and real-time methods (ecological momentary assessments) for 1 year. Reduce Anxiety and Depressive The fortnightly questionnaires will inquire about anxiety and depressive symptoms Symptoms. Front. Psychiatry 12:642763. [General Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9)] and the doi: 10.3389/fpsyt.2021.642763 frequency of 10 potential coping behaviors (e.g., follow a routine) during the past 2 weeks. Frontiers in Psychiatry | www.frontiersin.org 1 July 2021 | Volume 12 | Article 642763 Fortea et al. Coping With the Pandemics Protocol In addition, we will collect several variables that could confound or moderate these associations. These will include subjective well-being [International Positive and Negative Affect Schedule Short Form (I-PANAS-SF) and Satisfaction with Life Scale (SWLS)], obsessive-compulsive symptoms [Obsessive Compulsive Inventory-Revised (OCI-R)], personality and emotional intelligence [International Personality Item Pool (IPIP) and Trait Emotional Intelligence Questionnaire Short Form (TEIQue-SF)], sociodemographic factors (e.g., work status, housing-built environment), and COVID-19 pandemic-related variables (e.g., hospitalizations or limitations in social gatherings). Finally, to analyze the primary relationship between coping behaviors and subsequent anxiety and depressive symptoms, we will use autoregressive moving average (ARMA) models. Discussion: Based on the study results, we will develop evidence-based, clear, and specific recommendations on coping behaviors during the COVID-19 pandemic and lockdown. Such suggestions might eventually help health bodies or individuals to manage current or future pandemics. Keywords: COVID-19, anxiety, depressive symptoms, coping behaviors, longitudinal study INTRODUCTION behaviors and fewer mental health problems during the pandemic (9, 10). One study found that anxiety symptoms may Worldwide, the coronavirus disease 2019 (COVID-19) mediate the relationships between the threat of COVID-19 and pandemic and subsequent lockdowns might increase anxiety coping behaviors (11). Other studies have reported negative and depressive symptoms. Health bodies provided some associations between physical activity and general negative recommendations for coping with these symptoms (1). However, emotions, depression, loneliness, or stress (12, 13). And yet most recommendations rely on experiences (e.g., individual others have reported positive associations between social media prison isolation) that are probably very different from the exposure and anxiety and depression (14). current situation. The behaviors that may help a prisoner cope There are four general limitations in these previous studies. with isolation may not aid the general population cope with First, most were cross-sectional, i.e., they mainly “correlated” the pandemic and lockdown. Other recommendations rely the frequency of behaviors and the severity of symptoms on previous research on epidemics, such as the severe acute during the same period. Thus, we cannot rule out reverse respiratory syndrome (SARS) epidemic in 2003 or the influenza causation (mistaking a cause for effect and vice versa). For A pandemic in 2009 (2–5). For instance, Lau and colleagues instance, we found that reading news/updates about COVID-19 suggested that positive changes during the SARS epidemic, like correlated with increased anxiety. Still, it is uncertain whether spending more time resting, relaxing, or exercising, protected individuals first started reading news very often and afterward from the negative impacts of the epidemic (3). For other disasters got anxious, or the other way round, i.e., they got nervous, and such as terrorist attacks, coping behaviors such as information after that, they started reading news very often. Second, most search and social support have played a role (6). We do not know studies investigated a short period of the pandemic course. We whether these recommendations apply or could have similar cannot discard that the relationships might differ depending on effects in the current context. whether the pandemic or the lockdown restrictions endure or Our central hypothesis is that certain “simple” change. For instance, a longitudinal study in Wuhan residents coping behaviors, such as following a healthy diet, or found that psychological well-being slightly improved after the exercise might protect from the adverse psychological lockdown was lifted in early April 2020 (15), although the effects of the COVID-19 pandemic. Our objective is pandemic was not over. Third, most studies inquired about to find these behaviors, with the final aim to create symptoms retrospectively, which might potentially increase evidence-based recommendations. recall bias. Finally, most studies used convenience (and not We must note that some research groups have already representative) samples. conducted online surveys to investigate the subject (7). For To overcome these limitations, we will ask participants instance, in April 2020, we conducted a pilot survey of to answer fortnightly questionnaires for 1 year using a 5,000 Spanish adults 2 weeks after the government established prospective longitudinal design. We aim to assess the association an official lockdown across the country (8). We found between coping behaviors and subsequent anxiety and depressive that maintaining a healthy/balanced diet and not reading symptoms and whether these associations might change with news/updates about COVID-19 very often correlated with the COVID-19 pandemic and lockdown conditions. Besides, lower levels of anxiety and depressive symptoms. Other studies we will also include ecological momentary assessments (EMA) have also found significant associations between certain coping (16), close in time to experience to minimize recall bias. Finally, Frontiers in Psychiatry | www.frontiersin.org 2 July 2021 | Volume 12 | Article 642763 Fortea et al. Coping With the Pandemics Protocol the sample will be more representative of the Spanish general This preliminary survey will only include the informed consent, adult population. the questions about the four stratification variables, the 16 anxiety and depression items [General Anxiety Disorder-7 (GAD-7) (19) and Patient Health Questionnaire-9 (PHQ-9) (11)], and the METHODS AND ANALYSIS preferred channel to receive communications [via Short Message Design Service (SMS), email, or both]. We will inform the potential We will conduct an observational prospective, longitudinal study participants that we will randomly select 1,000 individuals and in a sample with a demographic distribution like the Spanish invite them to answer fortnightly questionnaires and EMA for general adult population. a year, receiving 140e compensation at the end of the study. We will highlight that only participants included in this second Recruitment step who complete ≥70% fortnightly questionnaires with <10% We will recruit a sample of 1,000 individuals who are willing to missing answers per questionnaire and ≥70% EMAs will receive answer online questionnaires every 2 weeks and EMA for 1 year. the compensation. The study’s target population will be the Spanish general adult population, probably excluding individuals not fluent in Spanish Sampling and individuals not reachable by social networks. Inclusion The number of participants selected from each specific stratum criteria will be: (a) age ≥ 18 years; (b) live in Spain; and (c) will depend on the stratum’s weight and the overall differences have a mobile phone number or email address to receive our between the sample and the population. We have calculated a notifications. Exclusion criteria will be: (a) fail to answer the “stratum-ideal” number of participants for each stratum that preliminary survey or the first online questionnaire; and (b) fail to ensures that the sample includes individuals from all strata, but answer more than eight online questionnaires and/or more than at the same time, larger strata in the population are larger in nine EMA during the follow-up. the sample. However, we will recruit up to five more individuals The sample size estimation relies on the observation that per stratum than this “stratum-ideal” number if their inclusion we could detect associations in our pilot study’s (8) interim reduces the statistically significant differences between the overall analyses when the sample size was still substantially smaller than sample and the population in age, sex, urbanicity, and region 1,000. Thus, while we cannot provide exact sample size/power (in this order of priority). To calculate the above “stratum- estimations for the time-series analyses described later, we must ideal” number, we retrieved the demographic distribution of note that a sample size of 1,000 would allow the detection of small the Spanish population from the National Statistics Institute Pearson correlations (r = 0.135) with 90% power after Bonferroni (20) and used the following iterative algorithm: (a) we first set correction for multiple testing (two outcomes × 10 behaviors). the size of each of the 350 sample strata to one participant; Recruitment will follow a two-step strategy (Figure 1). First, (b) we divided the population strata sizes by the sample strata we will conduct a “pre-recruitment” step to create a pool of sizes, obtaining the weight that we would apply to each stratum potential participants (who will not have the Spanish population’s in a weighted analysis; (c) we added one participant to the demographic distribution because some groups will be over- stratum with the largest weight; (d) we went back to (b). We will represented). Second, we will conduct a “sampling” step in exclude those individuals who do not respond correctly to the which, separately for different strata (see next paragraph), we will first questionnaire. randomly select several participants so that the final sample has a demographic distribution like the Spanish population. Follow-Up Similar to previous mental health epidemiological research We will contact the selected individuals by SMS and email. On in the Spanish population (17), stratification factors will Fridays, Mondays, and following Wednesdays, we will either include age group (18–34, 35–44, 45–54, 55–64, ≥65-year-old), confirm the participants that we have correctly received their gender (binary), region (Spanish autonomous community), and responses, inform them that their responses were incomplete urbanicity. We selected these five age groups because each group (≥10% missing answers) or potentially inaccurate/inconsistent, corresponds to ∼7.5 million individuals (18–34 years: 8.6 million; or remind them to answer the questionnaire. 35–44 years: 7.3 million; 45–54 years: 7.5 million; 55–64 years: We will use two strategies to detect potentially 6.3 million; ≥65 years: 9.3 million). For urbanicity, we will use inaccurate/inconsistent responses (i.e., indicators that the the municipality size threshold (<10,000 residents, vs. higher) participant may have paid low attention). On the one hand, used in the UK Household Longitudinal Study, which Pierce et we will look for significant discrepancies between two repeated al. used to assess the effects of urbanicity on mental health during questions included in each questionnaire (e.g., answering “not at the pandemic (18). all” and “nearly every day” to the same question). On the other hand, we will detect questionnaires answered in a few seconds, Pre-recruitment suggesting that the participant did not even read the questions. We will publicize the study on social networks, inviting Previous research has found that item 9 of PHQ9 (death everyone to participate in a preliminary survey. To reach thoughts) predicts risk for suicide attempts across age groups heterogeneous society sectors, we will ask close and distant (21). Therefore, we will send emails/SMS to individuals reporting acquaintances from varying ages and professions to invite close any frequency on this item advising them to check with their and distant acquaintances from varying ages and occupations. health care provider or, in case of thinking about harming Frontiers in Psychiatry | www.frontiersin.org 3 July 2021 | Volume 12 | Article 642763 Fortea et al. Coping With the Pandemics Protocol themselves, to go to an emergency service. That said, we will not Secondary Variables exclude any individual based on his/her scores because we aim to In the fortnightly questionnaires, we will also collect several represent the whole adult population. other variables for their use as covariates, modulators, or alternative outcomes. Assessments of psychological well-being other than anxiety and depression will include the 10-item International Positive Online Questionnaires and EMA and Negative Affect Schedule Short Form (I-PANAS-SF) (23), We will collect all participants’ information through an the 5-item Satisfaction with Life Scale (SWLS) (24), and the institutional safe online platform (https://enquesta.clinic.cat/). 18-item Obsessive Compulsive Inventory-Revised (OCI-R) (25). We have created a survey for the “pre-recruitment” step, several We will present subjective well-being scales (I-PANAS-SF and questionnaires for the fortnightly follow-up assessments, and a SWLS) every 6 weeks and the OCI-R twice (with a 6-month short two-item form for the EMA. Every week, we will send difference between the assessments). In the context of the current emails and SMS to the participants to answer a questionnaire or anti-pandemic frequent hand-washing recommendations, we an EMA using the platform. removed the two contamination/washing questions (items 11 We will not collect any personal information from the and 17) from the latter. The reason to include the OCI-R is participants. Instead, the Uniform Resource Locator (URL) links that pandemic contamination/hygienic measures may increase in the emails and SMS will include a unique random series of obsessive-compulsive symptoms. letters and numbers to determine which answers correspond to We will also assess personality and emotional intelligence the same participant across the various questionnaires and EMA. twice (with a 6-month difference between the assessments) with We will present the fortnightly questionnaires every 2 the 50-item International Personality Item Pool (IPIP) (26) Wednesdays. We understood that Wednesday is neither too and the Trait Emotional Intelligence Questionnaire Short Form close nor too far from the weekend, and thus the answers (TEIQue-SF) (27). We assume that personality and emotional will not be biased toward weekend or workday memories. The intelligence may modulate the individual response and adaption questionnaires will be short to increase the likelihood of response. to the crisis. Still, pandemic stress and restrictions could also The first page will include the 16 GAD-/PHQ-9 items, the second modulate our personality and emotional intelligence. page some questions about secondary variables, and the third To estimate the behaviors’ baseline frequency, we will ask the page the 10 behaviors and the two repeated questions. We will participants to think about their everyday life the two last weeks inquire about symptoms first to avoid response order bias (22). before the pandemic outbreak. We will prompt the participants to answer the EMA, asked We will also ask some general factors that may have an at any random time from Wednesday to Tuesday, from 10 am influence. We will include questions at the beginning of the to 6 pm. study and questions about their change for factors that we We will make minor modifications to this schedule to avoid considered might vary. They will be the work and telework special days such as Christmas. status, having minor or other dependent people in charge, COVID-19 diagnosis/severity/risk in one-self and close relatives, COVID-19 unrelated life events, and having received mental Main Variables health treatment for more than 3 months. Conversely, we will The study’s main dependent variables will be the anxiety and include questions only once for factors that we considered depressive symptoms (GAD-7 and PHQ-9). We will collect them more stable. They will consist of years of education, housing- every week: on the first page of the fortnightly questionnaires in built environment, household age composition, stance on even weeks and on the EMA in odd weeks. For the latter, we will vaccination, and COVID-19-related deaths in close relatives and only ask one representative item of each scale in the present tense acquaintances (dates asked at the end of the study). To assess (“Do you feel nervous, anxious, or on edge?,” “Do you feel down, the housing built environment, we will use the items used by depressed, or hopeless?”). Amerio et al. (e.g., housing dimension, livable outdoor space, The independent variables will be the frequency of these 10 views, indoor quality) to investigate its effects on mental health behaviors: follow a routine, talk with relatives/friends not living during COVID-19 lockdown (28). in the household, physical exercise, follow a healthy/balanced Finally, we will collect variables related to the effects of the diet, drinking water to hydrate, read news/updates about pandemic and lockdown measures, both at the national level and COVID-19 very often, take the opportunity to pursue hobbies separately for regions. We will download COVID-19 incidence, or conduct home tasks such as arranging the wardrobe, stay percentage of positive tests, the instantaneous reproduction outdoors or look outside, do relaxing activities, and interact number, hospitalizations, intensive care unit (ICU) admissions, with other individuals of the household (e.g., partner or and deaths from the Health Alert and Emergency Coordination children) (8). We chose these behaviors based on our previous Center (29). We will standardize (30) the lockdown restrictions study (8). We declined the possibility that participants could (e.g., limitations in social gatherings) from autonomous propose other behaviors because we ask all behaviors in all communities governments (31–52), and we will estimate the fortnightly questionnaires, but the participants join the study at number and emotional valence of Spain-originated tweets with different times. relevant keywords (e.g., “coronavirus” or “vaccine”) (53). Frontiers in Psychiatry | www.frontiersin.org 4 July 2021 | Volume 12 | Article 642763 Fortea et al. Coping With the Pandemics Protocol FIGURE 1 | Flowchart of the study. EMA, ecological momentary assessments; SMS, Short Message Service. Frontiers in Psychiatry | www.frontiersin.org 5 July 2021 | Volume 12 | Article 642763 Fortea et al. Coping With the Pandemics Protocol We acknowledge that many other factors may have an ask the participants to answer fortnightly questionnaires for 1 influence, e.g., the use of alcohol. However, we chose to limit the year and EMA in real-time to estimate the symptoms better. number of questions to keep the questionnaires short. Besides, Based on the study results, we will develop clear and the study’s main aim is to link coping behaviors with symptom specific recommendations about which coping behaviors may improvement, and these factors are only secondary variables. help us mitigate the anxiety and depressive symptoms during the COVID-19 pandemic and lockdown. We will then share Data Analysis these recommendations with health organizations, providers, The primary analysis will estimate the relationship between and public policymakers. coping behaviors and subsequent symptoms. We will use low- For each of the 20 relationships of interest (i.e., 10 order autoregressive moving average (ARMA) models, which coping behaviors modifying two primary outcomes), the results attempt to answer how past values and moving averages (e.g., may draw different scenarios. We will only exemplify the the average of the current and past 2 weeks) explain the relationship between reading news/updates about COVID-19 present symptoms. and subsequent anxiety symptoms for simplicity. However, we Before the analysis, we will do multiple imputations of understand that these interpretations would be similar for the the missing responses. In addition, we will also analyze the other relationships. characteristics of missing data (e.g., the relationship with A basic scenario could be that we observe that when other variables). individuals read news/updates about COVID-19 very often, We will account for potential confounds, baseline values, and their anxiety subsequently increases. This finding would support the effect of potentially modulating factors. To assess whether the previous interpretations that reading news/updates about results might depend on methodological factors, we will conduct COVID-19 increases anxiety (8), and thus the recommendations the following sensitivity analyses: (a) using GAD-7 and PHQ- to decrease the frequency of this behavior (1). However, we 9 from fortnightly questionnaires or the following EMA; (b) could also find that when individuals report high anxiety, they weighting or not weighting the strata for their population/sample subsequently increase the frequency of reading news/updates ratio; (c) excluding the questionnaires or participants with highly about COVID-19. This bidirectional relationship would lead to potentially inaccurate/inconsistent answers. a vicious circle: anxiety makes individuals read COVID-19 news For the analyses of alternative outcomes (e.g., I-PANAS- more often, in turn making them more anxious. Vicious circles SF), we will have fewer measurements of the outcomes than are indeed common in anxiety. For instance, anxiety may lead measurements of coping behaviors. To circumvent this problem, to avoiding feared stimuli, which in turn increases anxiety (55). we will time-weighted-average the coping behaviors measured We should then encourage people to avoid reading news/updates since the last measure of the outcome. Besides, fewer assessments about COVID-19 “too often.” might not allow us to fit ARMA models. In this case, we We may alternatively observe that when individuals read will fit simpler models (e.g., a pre-post repeated-measure linear news/updates about COVID-19 very often, their anxiety model). We also plan a series of other secondary analyses, such subsequently decreases. This finding would question previous as the relationship between the symptoms or restrictions and studies, up to the point that we should wonder whether we should subsequent personality or emotional intelligence changes. recommend reading COVID-19 news often to prevent anxiety. We will correct the primary analyses for multiple In additional analyses, we could also find that when individuals comparisons, and we will conduct all analyses with R (54). report high anxiety, they subsequently increase the frequency of reading COVID-19 news, thus suggesting reverse causation. We Creation of Recommendations could speculate that individuals with COVID-19-related anxiety The results of this longitudinal study will allow us to create learn that their anxiety decreases after reading COVID-19 news. evidence-based recommendations. Specifically, we will grade This amelioration would be the reason why they read COVID-19 the main results according to their effect size, statistical news more often. significance, and variation in the sensitivity analyses. When We may also find that the effect of reading “too often” the modulator analyses show that the effects might be sensibly COVID-19 news is modulated by personality traits, which different depending on a modulator, we will grade the results we also investigate in our study. This result would not be separately. Finally, we will write the most robust results as surprising because each Big Five personality is associated recommendations. We will send them to health organizations with different coping strategies. For example, extraversion and providers, and public policymakers, along with a text and conscientiousness are related to problem-solving and explaining the study and the grading. cognitive restructuring. In contrast, neuroticism is related to wishful thinking, withdrawal, and emotion-focused coping DISCUSSION (56). Therefore, we could offer more personalized suggestions (i.e., considering coping strategies and personality traits). This project aims to study the relationship between a set of Another potential modulator of the relationships between coping simple potential coping behaviors and subsequent anxiety and behaviors and subsequent anxiety or depressive symptoms may depressive symptoms in the context of the COVID-19 pandemic be emotional intelligence. A recent study in the context of the and associated lockdown restrictions. To this end, we will recruit COVID-19 pandemic showed indeed that emotional intelligence a sample with a demographic distribution like the population and is related to all coping strategies (57). Frontiers in Psychiatry | www.frontiersin.org 6 July 2021 | Volume 12 | Article 642763 Fortea et al. Coping With the Pandemics Protocol GAD-7 and PHQ9-9 ask about anxiety and depressive only compensate economically the participants who complete symptoms during the previous 2 weeks. Therefore, we expect that the follow-up. Fourth, we acknowledge the possibility that the GAD-7 and PHQ9-9 scores will strongly correlate with the participants modify their behavior in response to the assessments anxiety and depression levels measured with the EMA collected (i.e., the Hawthorne effect) (62). However, we will not focus on during those 2 weeks. However, we cannot give this for granted the behavioral changes but on the impact of these changes on because there may be some recall bias. For example, a recent anxiety and depressive symptoms. Finally, we must acknowledge study in patients with major depressive disorder found that that while this study will assess whether coping behaviors precede the severity of suicidal ideation assessed through 1-week EMA changes in symptoms, it is only observational. We would need a correlated with the ideation scores retrospective collected at the randomized controlled design to evaluate the “true” efficacy of end of the week. Still, many participants reporting ideation with coping behaviors in reducing anxiety and depressive symptoms. EMA denied ideation on the retrospective assessment (58). Thus, the analysis of the relationship between behaviors and EMA ETHICS STATEMENT scores will yield light on the relevance of this potential recall bias. Suppose the results are similar to those obtained using GAD-7 The study was reviewed and approved by Comitè d’Ètica de and PHQ9-9. In that case, we will conclude that the potential la Investigació amb medicaments, Hospital Clínic de Barcelona recall bias has no significant effects on our analyses. Conversely, if (protocol HCB/2020/0890). The participants will provide their the results are substantially different, we will report and interpret electronic informed consent to participate in this study. both results differently. We believe that the secondary analyses may also provide AUTHOR CONTRIBUTIONS interesting guidance. For instance, we may find that some coping behaviors have an only weak relationship with subsequent JR, MF, LF, AS, JA, CT, CB, DH-M, IG, and EV conceived the anxiety symptoms but a strong connection with obsessive- study. All authors participated in the redaction of the manuscript compulsive symptoms. We chose this outcome for its relevance including minor or major modifications of the protocol. during the pandemic; some studies have indeed observed an increase in obsessive-compulsive symptoms (59). Other FUNDING interesting alternative outcomes will be subjective well-being, personality, and emotional intelligence. Personality changes The AXA Research Fund supports this research via an AXA little during adulthood (60), but a few studies have found Award granted to JR from the call for projects “Mitigating that catastrophic trauma may potentially lead to personality risk in the wake of the Covid-19 Pandemic”. Additionally, changes (61). the Instituto de Salud Carlos III-Subdirección General de This project has some potential limitations. First, we may face Evaluación y Fomento de la Investigación and the European difficulties in recruiting the target sample. The recruitment may Regional Development Fund (FEDER, Investing in your future) seem straightforward if one keeps in mind that we will recruit supports CT (Miguel Servet Research Contract CPII19/00018), 1,000 participants in several weeks, while in the pilot study, JR (Miguel Servet Research Contract CPII19/00009), LF (PFIS we recruited 5,000 participants in <2 weeks. However, in the Predoctoral Contract FI20/00047), and SC (Miguel Servet pilot study, we only presented a single survey to a convenience Research Contract CPI16/00096). This work was also supported sample. Here, we will conduct a longitudinal study in a sample by Instituto de Salud Carlos III (Ministerio de Ciencia e with a demographic distribution like the population. Second, Innovación)/FEDER (COV20/00711) and by the Generalitat de as in any voluntary study, more altruistic individuals may tend Catalunya (2017 SGR 452). The funders have no role in the to participate more, although the compensation should reduce study’s design and conduct, collection, management, analysis, this potential participation bias. Third, a common problem and interpretation of the data, preparation, review, or approval of longitudinal studies is the loss of follow-up. To minimize of the manuscript, and decision to submit the manuscript this risk, we have created short questionnaires, and we will for publication. REFERENCES 4. Matsuishi K, Kawazoe A, Imai H, Ito A, Mouri K, Kitamura N, et al. Psychological impact of the pandemic (H1N1) 2009 on general 1. CDC. Coronavirus Disease 2019 (COVID-19) - Stress and Coping (2020). hospital workers in Kobe. Psychiatry Clin Neurosci. (2012) 66:353– Available online at: https://www.cdc.gov/coronavirus/2019-ncov/daily-life- 60. doi: 10.1111/j.1440-1819.2012.02336.x coping/managing-stress-anxiety.html 5. Taha S, Matheson K, Cronin T, Anisman H. Intolerance of uncertainty, 2. 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Personality trait EI and coping Copyright © 2021 Fortea, Solanes, Pomarol-Clotet, Garcia-Leon, Fortea, Torrent, with COVID 19 measures. Int J Disast Risk Reduct. (2020) Varo, Bonnin, Montejo, Alonso, Carmona, Soldevila-Matías, Alustiza, Arbós, 51:101789. doi: 10.1016/j.ijdrr.2020.101789 Hidalgo-Mazzei, Grande, Vieta, Fullana and Radua. This is an open-access article 58. Gratch I, Choo TH, Galfalvy H, Keilp JG, Itzhaky L, Mann JJ, et al. Detecting distributed under the terms of the Creative Commons Attribution License (CC BY). suicidal thoughts: the power of ecological momentary assessment. Depress The use, distribution or reproduction in other forums is permitted, provided the Anxiety. (2021) 38:8–16. doi: 10.1002/da.23043 original author(s) and the copyright owner(s) are credited and that the original 59. Cox RC, Olatunji BO. Linking insomnia and OCD symptoms during the publication in this journal is cited, in accordance with accepted academic practice. coronavirus pandemic: examination of prospective associations. J Anxiety No use, distribution or reproduction is permitted which does not comply with these Disord. (2021) 77:102341. doi: 10.1016/j.janxdis.2020.102341 terms. Frontiers in Psychiatry | www.frontiersin.org 9 July 2021 | Volume 12 | Article 642763