Journal Pre-proof

Impact of COVID-19 Pandemic on Mental Health in the General

Population: A Systematic Review

Jiaqi Xiong , Orly Lipsitz , Flora Nasri , Leanna M.W. Lui ,

Hartej Gill , Lee Phan , David Chen-Li , Michelle Iacobucci ,
Roger Ho , Amna Majeed , Roger S. McIntyre

PII: S0165-0327(20)32589-1
DOI: https://doi.org/10.1016/j.jad.2020.08.001
Reference: JAD 12306

To appear in: Journal of Affective Disorders

Received date: 22 June 2020

Revised date: 15 July 2020
Accepted date: 3 August 2020

Please cite this article as: Jiaqi Xiong , Orly Lipsitz , Flora Nasri , Leanna M.W. Lui , Hartej Gill ,
Lee Phan , David Chen-Li , Michelle Iacobucci , Roger Ho , Amna Majeed , Roger S. McIntyre ,
Impact of COVID-19 Pandemic on Mental Health in the General Population: A Systematic Review,
Journal of Affective Disorders (2020), doi: https://doi.org/10.1016/j.jad.2020.08.001

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Impact of COVID-19 Pandemic on Mental Health in the General Population: A Systematic Review

Jiaqi Xiong1, Orly Lipsitz, HBSc3, Flora Nasri, MSc3, Leanna M.W. Lui3, Hartej Gill, HBSc3, Lee Phan3,
David Chen-Li3, Michelle Iacobucci, HBSc3, Roger Ho, MD5,6, Amna Majeed3, Roger S. McIntyre,
MD1,2,3,4,* [email protected]
1
Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
2
Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
3
Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada
4
Brain and Cognition Discovery Foundation, Toronto, ON, Canada
5
Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of
Singapore, Singapore
6
Institute for Health Innovation and Technology (iHealthtech), National University of Singapore,
Singapore
*
Corresponding author: Dr. Roger S. McIntyre, MD, University Health Network, 399 Bathurst Street, MP
9-325, Toronto, ON M5T 2S8, Canada, Telephone: 416-603-5279, Fax: 416-603-5368

Highlights:

 The Coronavirus disease 2019 (COVID-19) pandemic has resulted in unprecedented

hazards to mental health globally.

 Relatively high rates of anxiety, depression, post-traumatic stress disorder, psychological

distress, and stress were reported in the general population during the COVID-19

pandemic in eight countries.

 Common risk factors associated with mental distress during the COVID-19 pandemic

include female gender, younger age group (≤40 years), presence of chronic/psychiatric

illnesses, unemployment, student status, and frequent exposure to social media/news

concerning COVID-19.

 Mitigation of COVID-19 induced psychological distress requires government

intervention and individual efforts.

Abstract

Background: As a major virus outbreak in the 21st century, the Coronavirus disease 2019 (COVID-19)

pandemic has led to unprecedented hazards to mental health globally. While psychological support is

being provided to patients and healthcare workers, the general public’s mental health requires significant

attention as well. This systematic review aims to synthesize extant literature that reports on the effects of

COVID-19 on psychological outcomes of the general population and its associated risk factors.

Methods: A systematic search was conducted on PubMed, Embase, Medline, Web of Science, and Scopus

from inception to 17 May 2020 following the PRISMA guidelines. A manual search on Google Scholar

was performed to identify additional relevant studies. Articles were selected based on the predetermined

eligibility criteria.

Results: Relatively high rates of symptoms of anxiety (6.33% to 50.9%), depression (14.6% to 48.3%),

post-traumatic stress disorder (7% to 53.8%), psychological distress (34.43% to 38%), and stress (8.1% to

81.9%) are reported in the general population during the COVID-19 pandemic in China, Spain, Italy, Iran,

the US, Turkey, Nepal, and Denmark. Risk factors associated with distress measures include female

gender, younger age group (≤40 years), presence of chronic/psychiatric illnesses, unemployment, student

status, and frequent exposure to social media/news concerning COVID-19.

Limitations: A significant degree of heterogeneity was noted across studies.

Conclusions: The COVID-19 pandemic is associated with highly significant levels of psychological

distress that, in many cases, would meet the threshold for clinical relevance. Mitigating the hazardous

effects of COVID-19 on mental health is an international public health priority.

Keywords

mental health; general population; anxiety; depression; Post-traumatic stress disorder (PTSD); COVID-19
1. Introduction

In December 2019, a cluster of atypical cases of pneumonia was reported in Wuhan, China,

which was later designated as Coronavirus disease 2019 (COVID-19) by the World Health Organization

(WHO) on 11 Feb 2020 (Anand et al., 2020). The causative virus, SARS-CoV-2, was identified as a

novel strain of coronaviruses that shares 79% genetic similarity with SARS-CoV from the 2003 SARS

outbreak (Anand et al., 2020). On 11 Mar 2020, the WHO declared the outbreak a global pandemic

(Anand et al., 2020).

The rapidly evolving situation has drastically altered people’s lives, as well as multiple aspects of

the global, public, and private economy. Declines in tourism, aviation, agriculture and the finance

industry owing to the COVID-19 outbreak are reported as massive reductions in both supply and demand

aspects of the economy were mandated by governments internationally (Nicola et al., 2020). The

uncertainties and fears associated with the virus outbreak, along with mass lockdowns and economic

recession are predicted to lead to increases in suicide as well as mental disorders associated with suicide.

For example, McIntyre and Lee (2020b) have reported a projected increase in suicide from 418 to 2,114

in Canadian suicide cases associated with joblessness. The foregoing result (i.e., rising trajectory of

suicide) was also reported in the USA, Pakistan, India, France, Germany, and Italy (Mamun and Ullah,

2020; Thakur and Jain, 2020). Separate lines of research have also reported an increase in psychological

distress in the general population, persons with pre-existing mental disorders, as well as in healthcare

workers (Hao et al., 2020; Tan et al., 2020; C. Wang 2020b). Taken together, there is an urgent call for

more attention given to public mental health and policies to assist people through this challenging time.

The objective of this systematic review is to summarize extant literature that reported on the

prevalence of symptoms of depression, anxiety, PTSD, and other forms of psychological distress in the

general population during the COVID-19 pandemic. An additional objective was to identify factors that

are associated with psychological distress.

2. Methods

Methods and results were formatted based on the Preferred Reporting Items for Systematic

Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2010).

2.1 Search strategy

A systematic search following the PRISMA 2009 flow diagram (Figure 1) was conducted on

PubMed, Medline, Embase, Scopus, and Web of Science from inception to 17 May 2020. A manual

search on Google Scholar was performed to identify additional relevant studies. The search terms that

were used were: (COVID-19 OR SARS-CoV-2 OR Severe acute respiratory syndrome coronavirus 2 OR

2019nCoV OR HCoV-19) AND (Mental health OR Psychological health OR Depression OR Anxiety OR

PTSD OR PTSS OR Post-traumatic stress disorder OR Post-traumatic stress symptoms) AND (General

population OR general public OR Public OR community). An example of search procedure was included

as a supplementary file.

2.2 Study selection and eligibility criteria

Titles and abstracts of each publication were screened for relevance. Full-text articles were

accessed for eligibility after the initial screening. Studies were eligible for inclusion if they: 1) followed

cross-sectional study design; 2) assessed the mental health status of the general population/public during

the COVID-19 pandemic and its associated risk factors; 3) utilized standardized and validated scales for

measurement. Studies were excluded if they: 1) were not written in English or Chinese; 2) focused on

particular subgroups of the population (e.g., healthcare workers, college students or pregnant women); 3)

were not peer-reviewed; 4) did not have full-text availability.

2.3 Data extraction

A data extraction form was used to include relevant data: (1) Lead author and year of publication,

(2) Country/region of the population studied, (3) Study design, (4) Sample size, (5) Sample

characteristics, (6) Assessment tools, (7) Prevalence of symptoms of depression/anxiety/

PTSD/psychological distress/stress, (8) Associated risk factors.

2.4 Quality appraisal

The Newcastle-Ottawa scale (NOS) adapted for cross-sectional studies was used for study quality

appraisal, which was modified accordingly from the scale used in Epstein et al. (2018). The scale consists

of three dimensions: Selection, Comparability, and Outcome. There are seven categories in total, which

assess the representativeness of the sample, sample size justification, comparability between respondents

and non-respondents, ascertainments of exposure, comparability based on study design or analysis,

assessment of the outcome, and appropriateness of statistical analysis. A list of specific questions was

attached as a supplementary file. A total of nine stars can be awarded if the study meets certain criteria,

with a maximum of four stars assigned for the selection dimension, a maximum of two stars assigned for

the comparability dimension, and a maximum of three stars assigned for the outcome dimension.

3. Results

3.1 Search results

In total, 648 publications were identified. Of those, 264 were removed after initial screening due

to duplication. 343 articles were excluded based on the screening of titles and abstracts. 41 full-text

articles were assessed for eligibility. There were 12 articles excluded for studying specific subgroups of

the population, five articles excluded for not having a standardized/ appropriate measure, three articles
excluded for being review papers, and two articles excluded for being duplicates. Following the full-text

screening, 19 studies met the inclusion criteria.

3.2 Study characteristics

Study characteristics and primary study findings are summarized in Table 1. The sample size of the

19 studies ranged from 263 to 52,730 participants, with a total of 93,614 participants. A majority of study

participants were over 18 years old. Female participants (n=60,005) made up 64.1% of the total sample.

All studies followed a cross-sectional study design. The 19 studies were conducted in eight different

countries, including China (n=10), Spain (n=2), Italy (n=2), Iran (n=1), the US (n=1), Turkey (n=1),

Nepal (n=1), and Denmark (n=1). The primary outcomes chosen in the included studies varied across

studies. Twelve studies included measures of depressive symptoms while 11 studies included measures of

anxiety. Symptoms of PTSD/psychological impact of events were evaluated in four studies while three

studies assessed psychological distress. It was additionally observed that four studies contained general

measures of stress. Three studies did not explicitly report the overall prevalence rates of symptoms;

notwithstanding the associated risk factors were identified and discussed.

3.3 Quality Appraisal

The result of the study quality appraisal is presented in Table 2. The overall quality of the

included studies is moderate, with total stars awarded varying from four to eight. There were two studies

with four stars, two studies with five stars, seven studies with six stars, seven studies with seven stars, and

one study with eight stars.

3.4 Measurement tools

 A variety of scales were used in the studies (n=19) for assessing different adverse psychological

outcomes. The Beck Depression Inventory-II (BDI-II), Patient Health Questionnaire-9/2 (PHQ-9/2), Self-

rating Depression Scales (SDS), The World Health Organization-Five Well-Being Index (WHO-5), and

Center for Epidemiologic Studies Depression Scale (CES-D) were used for measuring depressive

symptoms. The Beck Anxiety Inventory (BAI), Generalized Anxiety Disorder 7/2-item (GAD-7/2), and

Self-rating Anxiety Scale (SAS) were used to evaluate symptoms of anxiety. The Depression, Anxiety,

and Stress Scale- 21 items (DASS-21) was used for the evaluation of depression, anxiety and stress

symptoms. The Hospital Anxiety and Depression Scale (HADS) was used for assessing anxiety and

depressive symptoms. Psychological distress was measured by The Peritraumatic Distress Inventory

(CPDI) and the Kessler Psychological Distress Scale (K6). Symptoms of PTSD were assessed by The

Impact of Event Scale-(Revised) (IES(-R)), PTSD Checklist for DSM-5 (PCL-5). Chinese Perceived

Stress Scale (CPSS-10) was used in one study to evaluate symptoms of stress.

3.5 Symptoms of depression and associated risk factors

Symptoms of depression were assessed in 12 out of the 19 studies (Ahmed et al., 2020; Gao et al.,

2020; González-Sanguino et al., 2020; Huang and Zhao, 2020; Lei et al., 2020; Mazza et al., 2020;

Olagoke et al., 2020; Ozamiz-Etxebarria et al., 2020; S. Özdin and S.B. Özdin, 2020; Sønderskov et al.,

2020; C. Wang et al., 2020a; Y. Wang et al., 2020). The prevalence of depressive symptoms ranged from

14.6% to 48.3%. Although the reported rates are higher than previously estimated one-year prevalence

(3.6% and 7.2%) of depression among the population prior to the pandemic (Huang et al., 2019; Lim et

al., 2018), it is important to note that presence of depressive symptoms does not reflect a clinical

diagnosis of depression.

Many risk factors were identified to be associated with symptoms of depression amongst the

COVID-19 pandemic. Females were reported as are generally more likely to develop depressive
symptoms when compared to their male counterparts (Lei et al., 2020; Mazza et al., 2020; Sønderskov et

al., 2020; C. Wang et al., 2020a). Participants from the younger age group (≤40 years) presented with

more depressive symptoms (Ahmed et al., 2020; Gao et al., 2020; Huang and Zhao, 2020; Lei et al., 2020;

Olagoke et al., 2020; Ozamiz-Etxebarria et al., 2020;). Student status was also found to be a significant

risk factor for developing more depressive symptoms as compared to other occupational statuses (i.e.

employment or retirement) (González et al., 2020; Lei et al., 2020; Olagoke et al., 2020). Four studies

also identified lower education levels as an associated factor with greater depressive symptoms (Gao et

al., 2020; Mazza et al., 2020; Olagoke et al., 2020; C. Wang et al., 2020a). A single study by Y. Wang et

al. (2020) reported that people with higher education and professional jobs exhibited more depressive

symptoms in comparison to less educated individuals and those in service or enterprise industries.

Other predictive factors for symptoms of depression included living in urban areas, poor self-

rated health, high loneliness, being divorced/widowed, being single, lower household income, quarantine

status, worry about being infected, property damage, unemployment, not having a child, a past history of

mental stress or medical problems, having an acquaintance infected with COVID-19, perceived risks of

unemployment, exposure to COVID-19 related news, higher perceived vulnerability, lower self-efficacy

to protect themselves, the presence of chronic diseases, and the presence of specific physical symptoms

(Gao et al., 2020, González et al., 2020, Lei et al., 2020; Mazza et al., 2020; Olagoke et al., 2020;

Ozamiz-Etxebarria et al., 2020; S. Özdin and S.B. Özdin, 2020; C. Wang et al., 2020a).

3.6 Symptoms of anxiety and associated risk factors

Anxiety symptoms were assessed in 11 out of the 19 studies, with a noticeable variation in the

prevalence of anxiety symptoms ranging from 6.33% to 50.9% (Ahmed et al., 2020; Gao et al., 2020;

González-Sanguino et al., 2020; Huang and Zhao, 2020; Lei et al., 2020; Mazza et al., 2020;
Moghanibashi-Mansourieh, 2020; Ozamiz-Etxebarria et al., 2020; S. Özdin and S.B. Özdin, 2020; C.

Wang et al., 2020a; Y. Wang et al., 2020).

Anxiety is often comorbid with depression (Choi et al., 2020). Some predictive factors for

depressive symptoms also apply to symptoms of anxiety, including a younger age group (≤40 years),

lower education levels, poor self-rated health, high loneliness, female gender, divorced/widowed status,

quarantine status, worry about being infected, property damage, history of mental health issue/medical

problems, presence of chronic illness, living in urban areas, and the presence of specific physical

symptoms (Ahmed et al., 2020; Gao et al., 2020; Gonzáles et al., 2020; Huang and Zhao, 2020; Lei et al.,

2020; Mazza et al., 2020; Moghanibashi-Mansourieh, 2020; Ozamiz et al., 2020; S. Özdin and S.B.

Özdin, 2020; C. Wang et al., 2020a; Y. Wang et al., 2020).

Additionally, social media exposure or frequent exposure to news/information concerning

COVID-19 was positively associated with symptoms of anxiety (Gao et al., 2020; Moghanibashi-

Mansourieh, 2020). With respect to marital status, one study reported that married participants had higher

levels of anxiety when compared to unmarried participants (Gao et al., 2020). On the other hand, Lei et al.

(2020) found that divorced/widowed participants developed more anxiety symptoms than single or

married individuals. A prolonged period of quarantine was also correlated with higher risks of anxiety

symptoms. Intuitively, contact history with COVID-positive patients or objects may lead to more anxiety

symptoms, which is noted in one study (Moghanibashi-Mansourieh, 2020).

3.7 Symptoms of PTSD/ psychological distress/stress and associated risk factors

With respect to PTSD symptoms, similar prevalence rates were reported by Zhang and Ma (2020)

and N. Liu et al. (2020) at 7.6% and 7%, respectively. Despite using the same measurement scale as

Zhang and Ma (2020) (i.e., IES), C. Wang et al. (2020a) noted a remarkably different result, with 53.8%

of the participants reporting moderate-to-severe psychological impact. González et al. (2020) noted
15.8% of participants with PTSD symptoms. Three out of the four studies that measured the traumatic

effects of COVID-19 reported that the female gender was more susceptible to develop symptoms of

PTSD. In contrast, the research conducted by Zhang and Ma (2020) found no significant difference in IES

scores between females and males. Other risk factors included loneliness, individuals currently residing in

Wuhan or those who have been to Wuhan in the past several weeks (the hardest-hit city in China),

individuals with higher susceptibility to the virus, poor sleep quality, student status, poor self-rated health,

and the presence of specific physical symptoms. Besides sex, Zhang and Ma (2020) found that age, BMI,

and education levels are also not correlated with IES-scores.

Non-specific psychological distress was also assessed in three studies. One study reported a

prevalence rate of symptoms of psychological distress at 38% (Moccia et al., 2020), while another study

from Qiu et al. (2020) reported a prevalence of 34.43%. The study from H. Wang et al. (2020) did not

explicitly state the prevalence rates, but the associated risk factors for higher psychological distress

symptoms were reported (i.e., younger age groups and female gender are more likely to develop

psychological distress) (Qiu et al., 2020; H. Wang et al., 2020). Other predictive factors included being

migrant workers, profound regional severity of the outbreak, unmarried status, the history of visiting

Wuhan in the past month, higher self-perceived impacts of the epidemic (Qiu et al., 2020; H. Wang et al.,

2020). Interestingly, researchers have identified personality traits to be predictive of psychological

distresses. For example, persons with negative coping styles, cyclothymic, depressive, and anxious

temperaments exhibit a greater susceptibility to psychological outcomes (H. Wang et al., 2020; Moccia et

al., 2020).

The intensity of overall stress was evaluated and reported in four studies. The prevalence of

overall stress was variably reported between 8.1% to over 81.9% (C. Wang et al., 2020a; Samadarshi et

al., 2020; Mazza et al., 2020). Females and the younger age group are often associated with higher stress

levels as compared to males and the elderly. Other predictive factors of higher stress levels include

student status, higher number of lockdown days, unemployment, having to go out to work, having an
acquaintance infected with the virus, presence of chronic illnesses, poor self-rated health, and presence of

specific physical symptoms (C. Wang et al., 2020a; Samadarshi et al., 2020; Mazza et al., 2020).

3.8 A separate analysis of negative psychological outcomes

Out of the nineteen included studies, five studies appeared to be more representative of the

general population based on the results of study quality appraisal (Table 1). A separate analysis was

conducted for a more generalizable conclusion. According to the results of these studies, the rates of

negative psychological outcomes were moderate but higher than usual, with anxiety symptoms ranging

from 6.33% to 18.7%, depressive symptoms ranging from 14.6% to 32.8%, stress symptoms being

27.2%, and symptoms of PTSD being approximately 7% (Lei et al., 2020; N. Liu et al., 2020; Mazza et

al., 2020; Y. Wang et al., 2020; Zhang et al., 2020). In these studies, female gender, younger age group

(≤40 years), and student population were repetitively reported to exhibit more adverse psychiatric

symptoms.

3.9 Protective factors against symptoms of mental disorders

In addition to associated risk factors, a few studies also identified factors that protect individuals

against symptoms of psychological illnesses during the pandemic. Timely dissemination of updated and

accurate COVID-19 related health information from authorities was found to be associated with lower

levels of anxiety, stress, and depressive symptoms in the general public (C. Wang et al., 2020a).

Additionally, actively carrying out precautionary measures that lower the risk of infection, such as

frequent handwashing, mask-wearing, and less contact with people also predicted lower psychological

distress levels during the pandemic (C. Wang et al., 2020a). Some personality traits were shown to

correlate with positive psychological outcomes. Individuals with positive coping styles, secure and

avoidant attachment styles usually presented fewer symptoms of anxiety and stress (H. Wang et al., 2020;
Moccia et al., 2020). Y. Zhang et al (2020) also found that participants with more social support and time

to rest during the pandemic exhibited lower stress levels.

4. Discussion

Our review explored the mental health status of the general population and its predictive factors

amid the COVID-19 pandemic. Generally, there is a higher prevalence of symptoms of adverse

psychiatric outcomes among the public when compared to the prevalence before the pandemic (Huang et

al., 2019; Lim et al., 2018). Variations in prevalence rates across studies were noticed, which could have

resulted from various measurement scales, differential reporting patterns, and possibly

international/cultural differences. For example, some studies reported any participants with scores above

the cut-off point (mild-to-severe symptoms), while others only included participants with moderate-to-

severe symptoms (Moghanibashi-Mansourieh, 2020; C. Wang et al., 2020a). Regional differences existed

with respect to the general public's psychological health during a massive disease outbreak due to varying

degrees of outbreak severity, national economy, government preparedness, availability of medical

supplies/ facilities, and proper dissemination of COVID-related information. Additionally, the stage of the

outbreak in each region also affected the psychological responses of the public. Symptoms of adverse

psychological outcomes were more commonly seen at the beginning of the outbreak when individuals

were challenged by mandatory quarantine, unexpected unemployment, and uncertainty associated with

the outbreak (Ho et al., 2020). When evaluating the psychological impacts incurred by the coronavirus

outbreak, the duration of psychiatric symptoms should also be taken into consideration since acute

psychological responses to stressful or traumatic events are sometimes protective and of evolutionary

importance (Yaribeygi et al., 2017; Brosschot et al., 2016; Gilbert, 2006). Being anxious and stressed

about the outbreak mobilizes people and forces them to implement preventative measures to protect
themselves. Follow-up studies after the pandemic may be needed to assess the long-term psychological

impacts of the COVID-19 pandemic.

4.1 Populations with greater susceptibility

Several predictive factors were identified from the studies. For example, females tended to be

more vulnerable to develop the symptoms of various forms of mental disorders during the pandemic,

including depression, anxiety, PTSD, and stress, as reported in our included studies (Ahmed et al., 2020;

Gao et al., 2020; Lei et al., 2020). Greater psychological distress arose in women partially because they

represent a higher percentage of the workforce that may be negatively affected by COVID-19, such as

retail, service industry, and healthcare. In addition to the disproportionate effects that disruption in the

employment sector has had on women, several lines of research also indicate that women exhibit

differential neurobiological responses when exposed to stressors, perhaps providing the basis for the

overall higher rate of select mental disorders in women (Goel et al., 2014; Eid et al., 2019).

Individuals under 40 years old also exhibited more adverse psychological symptoms during the

pandemic (Ahmed et al., 2020; Gao et al., 2020; Huang and Zhao, 2020). This finding may in part be due

to their caregiving role in families (i.e., especially women), who provide financial and emotional support

to children or the elderly. Job loss and unpredictability caused by the COVID-19 pandemic among this

age group could be particularly stressful. Also, a large proportion of individuals under 40 years old

consists of students who may also experience more emotional distress due to school closures, cancellation

of social events, lower study efficiency with remote online courses, and postponements of exams (Cao et

al., 2020). This is consistent with our findings that student status was associated with higher levels of

depressive symptoms and PTSD symptoms during the COVID-19 outbreak (Lei et al., 2020; Olagoke et

al., 2020, C. Wang et al., 2020a; Samadarshi et al., 2020).

 People with chronic diseases and a history of medical/ psychiatric illnesses showed more

symptoms of anxiety and stress (Mazza et al., 2020; Ozamiz-Etxebarria et al., 2020; S. Özdin and S.B.

Özdin, 2020). The anxiety and distress of chronic disease sufferers towards the coronavirus infection

partly stem from their compromised immunity caused by pre-existing conditions, which renders them

susceptible to the infection and a higher risk of mortality, such as those with systemic lupus

erythematosus (Sawalha et al., 2020). Several reports also suggested that a substantially higher death rate

was noted in patients with diabetes, hypertension and other coronary heart diseases, yet the exact causes

remain unknown (Guo et al., 2020; Emami et al., 2020), leaving those with these common chronic

conditions in fear and uncertainty. Additionally, another practical aspect of concern for patients with pre-

existing conditions would be postponement and inaccessibility to medical services and treatment as a

result of the COVID-19 pandemic. For example, as a rapidly growing number of COVID-19 patients

were utilizing hospital and medical resources, primary, secondary, and tertiary prevention of other

diseases may have unintentionally been affected. Individuals with a history of mental disorders or current

diagnoses of psychiatric illnesses are also generally more sensitive to external stressors, such as social

isolation associated with the pandemic (Ho et al., 2020).

4.2 COVID-19 related psychological stressors

Several studies identified frequent exposure to social media/news relating to COVID-19 as a

cause of anxiety and stress symptoms (Gao et al., 2020; Moghanibashi-Mansourieh, 2020). Frequent

social media use exposes oneself to potential fake news/reports/disinformation and possibility for

amplified anxiety. With the unpredictable situation and a lot of unknowns about the novel coronavirus,

misinformation and fake news are being easily spread via social media platforms (Erku et al., 2020),

creating unnecessary fears and anxiety. Sadness and anxious feelings could also arise when constantly

seeing members of the community suffering from the pandemic via social media platforms or news

reports (Li et al., 2020).

 Reports also suggested that poor economic status, lower education level, and unemployment are

significant risk factors for developing symptoms of mental disorders, especially depressive symptoms

during the pandemic period (Gao et al., 2020; Lei et al., 2020; Mazza et al., 2020; Olagoke et al., 2020; ).

The coronavirus outbreak has led to strictly imposed stay-home-order and a decrease in demands for

services and goods (Nicola et al., 2020), which has adversely influenced local businesses and industries

worldwide. Surges in unemployment rates were noted in many countries (Statistics Canada, 2020;

Statista, 2020). A decrease in quality of life and uncertainty as a result of financial hardship can put

individuals into greater risks for developing adverse psychological symptoms (Ng et al., 2013).

4.3 Efforts to reduce symptoms of mental disorders

4.3.1 Policymaking

The associated risk and protective factors shed light on policy enactment in an attempt to relieve

the psychological impacts of the COVID-19 pandemic on the general public. Firstly, more attention and

assistance should be prioritized to the aforementioned vulnerable groups of the population, such as the

female gender, people from age group ≤40, college students, and those suffering from chronic/psychiatric

illnesses. Secondly, governments must ensure the proper and timely dissemination of COVID-19 related

information. For example, validation of news/reports concerning the pandemic is essential to prevent

panic from rumours and false information. Information about preventative measures should also be

continuously updated by health authorities to reassure those who are afraid of being infected (Tran, et al.,

2020a). Thirdly, easily accessible mental health services are critical during the period of prolonged

quarantine, especially for those who are in urgent need of psychological support and individuals who

reside in rural areas (Tran, et al., 2020b). Since in-person health services are limited and delayed as a

result of COVID-19 pandemic, remote mental health services can be delivered in the form of online
consultation and hotlines (S. Liu et al., 2020; Pisciotta et al., 2019). Last but not least, monetary support

(e.g. beneficial funds, wage subsidy) and new employment opportunities could be provided to people who

are experiencing financial hardship or loss of jobs owing to the pandemic. Government intervention in the

form of financial provisions, housing support, access to psychiatric first aid, and encouragement at the

individual level of healthy lifestyle behaviour has been shown effective in alleviating suicide cases

associated with economic recession (McIntyre and Lee, 2020a). For instance, declines in suicide

incidence were observed to be associated with government expenses in Japan during the 2008 economic

depression (McIntyre and Lee, 2020a).

4.3.2 Individual efforts

Individuals can also take initiatives to relieve their symptoms of psychological distress. For

instance, exercising regularly and maintaining a healthy diet pattern have been demonstrated to

effectively ease and prevent symptoms of depression or stress (Carek et al., 2011; Molendijk., 2018;

Lassale et al., 2019). With respect to pandemic-induced symptoms of anxiety, it is also recommended to

distract oneself from checking COVID-19 related news to avoid potential false reports and contagious

negativity. It is also essential to obtain COVID-19 related information from authorized news agencies and

organizations and to seek medical advice only from properly trained healthcare professionals. Keeping in

touch with friends and family by phone calls or video calls during quarantine can ease the distress from

social isolation (Hwang et al., 2020).

4.4 Strengths

Our paper is the first systematic review that examines and summarizes existing literature with

relevance to the psychological health of the general population during the COVID-19 outbreak and

highlights important associated risk factors to provide suggestions for addressing the mental health crisis

amid the global pandemic.

4.5 Limitations

Certain limitations apply to this review. Firstly, the description of the study findings was

qualitative and narrative. A more objective systematic review could not be conducted to examine the

prevalence of each psychological outcome due to a high heterogeneity across studies in the assessment

tools used and primary outcomes measured. Secondly, all included studies followed a cross-sectional

study design and, as such, causal inferences could not be made. Additionally, all studies were conducted

via online questionnaires independently by the study participants, which raises two concerns: 1]

Individual responses in self-assessment vary in objectivity when supervision from a professional

psychiatrist/ interviewer is absent, 2] People with poor internet accessibility were likely not included in

the study, creating a selection bias in the population studied. Another concern is the over-representation

of females in most studies. Selection bias and over-representation of particular groups indicate that most

studies may not be representative of the true population. Importantly, studies in inclusion were conducted

in a limited number of countries. Thus generalizations of mental health among the general population at a

global level should be made cautiously.

5. Conclusion

This systematic review examined the psychological status of the general public during the

COVID-19 pandemic and stressed the associated risk factors. A high prevalence of adverse psychiatric

symptoms was reported in most studies. The COVID-19 pandemic represents an unprecedented threat to

mental health in high, middle, and low-income countries. In addition to flattening the curve of viral

transmission, priority needs to be given to prevention of mental disorders (e.g. major depressive disorder,

PTSD, as well as suicide). A combination of government policy that integrates viral risk mitigation with

provisions to alleviate hazards to mental health are urgently needed.

Authorship Contribution Statement

JX contributed to the overall design, article selection and review and manuscript preparation. LL and JX

contributed to study quality appraisal. All other authors contributed to review, editing and submission.

mmc1.docx

Acknowledgements

RSM has received research grant support from the Stanley Medical Research Institute and the Canadian

Institutes of Health Research/Global Alliance for Chronic Diseases/National Natural Science Foundation

of China and speaker/consultation fees from Lundbeck, Janssen, Shire, Purdue, Pfizer, Otsuka, Allergan,

Takeda, Neurocrine, Sunovion, and Minerva.

Declaration of Competing Interest

None

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n = 645 records identified


Identification

n= 279 PubMed
 n= 124 Embase
 n= 61 Scopus
 n= 57 Web of Science
 n= 124 Medline Additional records identified through
manual searching
(n = 3 )

Records after duplicates removed

(n = 384 )
Screening

Titles and abstracts screened Records excluded

(n = 384) (n = 343)
 Eligibility

Full-text articles assessed for Full-text articles excluded, with reasons

eligibility (n = 22)
(n = 41 )
 12 articles removed for studying
subgroups of population
 5 articles removed for not using
validated measurement tools
 3 articles removed for being
review paper
 2 articles removed for being
duplicates

Studies included in qualitative

Included

synthesis
(n = 19 )

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) study
selection flow diagram.

Table 1. Summary of study sample characteristics, study design, assessment tools used, prevalence rates
and associated risk factors.

Lead Author Country Study design Sample Sample Assessment Prevalence Common assoc
/year size Characteristics tool n/total (%)
(n=)
Ahmed et al China Cross- 1,074 Age range: 14-68 BAI, BDI-II Anxiety symptoms: Chi-square test:
2020 sectional Mean age: 311/1,074 (29%)
study 33.54±11.13 Anxiety: Age gr
Sex(f/m):503/571 Depressive Depression: Age
symptoms: years).
398/1,074 (37.1%)
Gao et al 2020 China Cross- 4,872 Age range: 18-85 GAD-7, Anxiety symptoms: Logistic regress
sectional Mean age: 32.3±10.0 WHO-5 1,091/4,827
study Sex(f/m): (22.6%) Anxiety: Age gr
3,267/1,560 lower education
Depressive school degree),
symptoms: rated health, freq
2,331/4,827 exposure (SME)
(48.3%) Depression: Age
and 31-40 years
level (middle sc
in urban area, po
González- Spain Cross- 3,480 Age range: 18-80 GAD-2, Anxiety symptoms: Linear regressio
Sanguino et al sectional Mean age: 37.92 PCL-C-2, 752/3,480 (21.6%)
2020 study Sex(f/m): 2,610/870 PHQ-2 Anxiety: Loneli
Depressive receiving too mu
symptoms: Depression: Lon
651/3,480 (18.7%) status.
PTSD symptom
PTSD symptoms: female gender, h
550/3,480 (15.8%)
Huang et al China Cross- 7,236 Age range: 6-80 CES-D, Anxiety symptoms: Logistic regress
2020 sectional Mean age: 35.3±5.6 GAD-7 2,540/7,236
study Sex(f/m): (35.1%) Anxiety: Young
3,952/3,284 years), time spen
Depressive COVID-19 (≥3
symptoms: Depression: You
1,454/7,236 (<35 years).
(20.1%)
Lei at al 2020 China Cross- 1,593 Age range: ≥18 SAS, SDS Anxiety symptoms: Linear regressio
sectional Mean age: 32.3±9.8 132/1,593 (8.3%)
study Sex(f/m): 976/617 Anxiety: Female
Depressive age group (<30
symptoms: divorced/widow
233/1,593 (14.6%) region, living in
poor self-perceiv
by quarantine, w
infected, proper
Depression: Fem
age group (<30
divorced/widow
student status, li
affected area, lo
income, poor se
affected by quar
about being infe
damage.
N. Liu et al China Cross- 285 Age range: ≥18 PCL-5 PTSD symptoms: Hierarchical reg
2020 sectional Mean age: N/A 20/285 (7%)
study Sex(f/m): 155/130 PTSD symptom
poor sleep quali
asleep.
Mazza et al Italy Cross- 2,766 Age range: 18-90 DASS-21 Anxiety symptoms: Multivariate ord
2020 sectional Mean age: 517/2,766 (18.7%) regression analy
study 32.94±13.2
Sex(f/m): 1,982/784 Depressive Anxiety: Young
symptoms: having a family
906/2,766 (32.8%) with COVID-19
mental stress/me
Stress symptoms: Depression: Low
752/2,766 (27.2%) female gender, u
having a child, h
acquaintance inf
19, having a his
stress/medical p
Stress: Young a
having to go out
acquaintance inf
having a history
stress/medical p
Moccia et al Italy Cross- 500 Age range: 18-75 K10 Symptoms of Logistic regress
2020 sectional Mean age: N/A psychological
study Sex(f/m): 298/202 distress: Psychological d
190/500 (38%) cyclothymic, de
temperaments, i
attachment dime
approval”.

Moghanibashi- Iran Cross- 10,754 Age range: N/A DASS-21 Mild-to-severe Inferential statis
Mansourieh sectional Mean age: N/A anxiety symptoms: (ANOVA, Chi-s
2020 study Sex(f/m): (Anxiety 5,472/10,754 independent t-te
7,072/3,681 subscale) (50.9%)
Anxiety: Residin
19 affected regio
*Mild-to-average: younger age gro
3,419/10,754 (31.8%)
higher education
Severe-to-very severe: frequently follow
2,053/10,754 (19.1%) news, having fam
infected by COV
Olagoke et al USA Cross- 501 Age range: ≥18 PHQ-2 Depressive One-way ANOV
2020 sectional Mean age: symptoms: N/A correlation analy
study 32.44±11.94
Sex(f/m): 277/224 Depressive sym
lower education
income, student
*Occurrences of risk of unemplo
depressive symptoms
were stratified based on
related news exp
socio-demographic people with high
information. vulnerability, pe
efficacy to prote
Ozamiz- Spain Cross- 976 Age range: 18-78 DASS-21 Symptoms of Descriptive anal
Etxebarria et sectional Mean age: N/A depression/anxiety/
al 2020 study Sex(f/m): 792/184 stress: N/A Anxiety, depres
Younger individ
* Rates of depression, old), people with
anxiety, stress symptoms
were stratified based on
sociodemographic
information (e.g. sex,
age, etc.).

Özdin et al Turkey Cross- 343 Age range: ≥18 HADS Anxiety symptoms: Linear regressio
2020 sectional Mean age: 155/343 (45.1%)
study 37.16±10.31 Anxiety: Female
Sex(f/m): 169/174 Depressive urban areas and
symptoms: previous psychia
81/343 (23.6%) Depression: Liv

Qiu et al 2020 China Cross- 52,730 Age range: N/A CPDI Symptoms of Logistic regress
sectional Mean age: N/A psychological
study Sex(f/m): distress: Psychological d
34,131/18,599 18,155/52,730 gender, age grou
(34.43%) years), occupati
workers), region
disease (middle
Samadarshi et Nepal Cross- 374 Age range: N/A CPSS-10 Moderate to high Logistic regress
al 2020 sectional Mean age: N/A stress symptoms:
study Sex(f/m):195/179 307/374 (82%) Stress: Student s
(<30 years).

Sønderskov et Denmark Cross- 2,458 Age range: N/A WHO-5 Depressive Two sample t-te
al 2020 sectional Mean age: 49.1 symptoms: correlation analy
study Sex(f/m): 624/2,458 (25.4%)
1,254/1,204 Depression: Fem
levels of self-pe
and anxiety.

C. Wang et al China Cross- 1,210 Age range: 12-59 IES-R, Symptoms of Linear regressio
2020 sectional Mean age: N/A DASS-21 psychological
study Sex(f/m): 814/396 impact: Common risk fa
651/1,210 (53.8%) symptoms: Fem
status, poor self-
Depressive specific physica
symptoms: myalgia, dizzine
300/1,210 (16.5%) dissatisfaction a
of COVID-19 re
Anxiety symptoms:
348/1,210 (28.8%) Anxiety: Contac
COVID+ patien
Stress symptoms:
98/1,210 (8.1%)
H. Wang et al China Cross- 1,599 Age range: 18-84 K6 Symptoms of Linear regressio
2020 sectional Mean age: 33.9±12.3 psychological
study Sex(f/m): 1,068/531 distress: N/A Psychological d
unmarried, histo
Wuhan in the pa
more impacts of
epidemic related
coping styles.

Y. Wang et al China Cross- 600 Age range: 18-72 SAS, SDS Anxiety symptoms: Logistic regress
2020 sectional Mean age: 34±12 38/600 (6.33%)
study Sex(f/m): 333/267 Anxiety: Female
Depressive (≤40 years).
symptoms: Depression: Hig
103/600 (17.17%) (master's degree
Occupation (pro
Zhang et al China Cross- 263 Age range: ≥18 IES Psychological Linear regressio
2020 sectional Mean age: 37.7±14.0 impact (IES≥26):
study Sex(f/m): 157/106 20/263 (7.6%) Psychological im

* Sex, age, BMI, an

significantly associa

Table 2. Results of study quality appraisal of the included studies.

Study Total Selection Comparability Ou

score
Representativeness Sample Non- Ascertainments Based on design Assessment of
of the sample size respondents of exposure and analysis outcome

Ahmed 2020 6 * * ** *
Gao 2020 6 * * ** *
González- 4 * * *
Sanguino
2020
Huang 2020 6 * * ** *
Lei 2020 7 * * * ** *
N. Liu 2020 8 * * * * ** *
Mazza 2020 7 * * * ** *
Moccia 2020 7 * * * ** *
Moghanibashi 6 * * ** *
-Mansourieh
2020
Olagoke 2020 6 * * ** *
Ozamiz- 5 * * ** *
Etxebarria
2020
Özdin 2020 7 * * * ** *
Qiu 2020 4 * * *
Samadarshi 7 * * * ** *
2020
Sønderskov 5 * * * *
2020
C. Wang 2020 6 * * ** *
H. Wang 2020 6 * * ** *
Y. Wang 2020 7 * * * ** *
Zhang 2020 7 * * * ** *