Mental health consequences of the Covid-19 outbreak in Spain

The objective is to analyze the effects of the pandemic and alarm situation on the psychological health, loneliness, intersectional discrimination and spiritual wellbeing of the general population in a longitudinal way in three moments: after two weeks of the beginning of the confinement (between March 21 and 29), after a month (between April 13 and 27), and after two months (between May 21 and June 4), with the beginning of the deconfinement and return to the new normality. The study received the approval of the Deontological Commission of the Faculty of Psychology of the Complutense University of Madrid (pr_2019_20_029) prior to its implementation. The signing of the informed consent and acceptance of the data protection laws was also included in the evaluation. The evaluations were carried out by means of an online survey, with a sample of 3480 persons in the first data collection and of 1041 and 569 persons in the successive moments of evaluation. The presence of depressive symptoms, anxiety and posttraumatic stress disease (PTSD) was evaluated by means of screening tests. Sociodemographic data, variables about Covid-19, loneliness, psychological well-being, social support, discrimination and a sense of belonging were collected.

Participants

Recruitment consisted of sending requests for participation to people belonging to databases of different institutions: students and workers in public organizations such as the Complutense University of Madrid and the academic Chair Against Stigma, and private organizations such as the company Group 5. These databases contain sufficient data to perform reasonable sampling of the Spanish population. To increase the sample size as much as possible participants were asked to help with its dissemination. The percentage of people recruited in this way was small, estimated as less than 5%. The inclusion criteria were: 1. To be over 18 years old; 2. To be living in Spain during the Covid-19 health emergency; 3. To have agreed to participate in the second evaluation of the study.

A total of 3480 people participated in the first evaluation. For the subsequent evaluations, those people who had previously agreed to participate in the study were contacted by email in a longitudinal way (specific section of the evaluation), recruiting a total of N = 1041 in the second data collection, and in the third evaluation N = 569.

In the resulting sample, a majority of women (81%) was obtained as opposed to 51% of the general population. With respect to age, a greater equivalence was obtained, although with a higher percentage of people under 60 years than in the general population: 29% (18-30), 64% (31-59) and 7% (60-80) for the three respective groups, compared to 10%, 44% and 19% for the general population (the remaining 5% do not meet the criteria for inclusion/exclusion).

Variables and instruments

The following variables and instruments were included in the assessment:

Sociodemographic variables

Using ad hoc questions, data was collected on age (subsequently grouped into clusters: 18-30, 31-59, 60-80); gender identity; marital status (single, married, divorced, separated, widower); educational level (elementary studies, high school, vocational training, university, postgraduate); economic situation (subjective perception from very bad to very good).

COVID-19 related variables

Suffering from symptoms (yes, no); existence of a family members or close relatives who are infected (yes, no); perception of the information received on the alarm situation (considering that they have sufficient information, or that they are over-informed). 

Mental health

Mental health was assessed with the PHQ-4 composed by the Patient Health Questionnaire 2 (PHQ-2) (Kroenke, Spitzer, Williams, & Löwe, 2009) and the Generalized Anxiety Disorder Scale (GAD-2) (Spitzer, Kroenke, Williams, & Löwe, 2006). The PHQ-2 was used in its Spanish version (Diez-Quevedo, Rangil, Sanchez-Planell, Kroenke, & Spitzer, 2001) and is a brief self-report questionnaire that addresses the frequency of depressive symptoms. It consists of 2 Likert-type questions ranging from 0 “never” to 3 “every day”. Higher scores indicate greater symptomatology, providing a severity score that ranges from 0 to 6. GAD-2 was also used in its Spanish version (Garcia-Campayo et al., 2014). The GAD-2 Questionnaire includes the first 2 items of the GAD-7 Likert format, with a maximum score of 6 points.

Loneliness

Measured by the 3 item version of the UCLA Loneliness Scale (UCLA-3) in its Spanish version and self-applied (Russell 1996; Velarde-Mayol et al. 2016). The three items in Likert format with three response options (1 rarely, 2 sometimes, 3 often), address three dimensions of loneliness: relational connection, social connection, and self-perceived isolation.

Intersectional discrimination

Intersectional discrimination was evaluated by means of the Intersectional Day-to-Day Discrimination Index (InDI-D) (Scheim & Bauer, 2019), in its Spanish version, which was translated by the authors of this study. This scale provides a measure of the intersectional discrimination that can be produced by different conditions: gender, ethnicity, mental health diagnosis, and in this case, the presence of COVID-19 was also included. We used the main scale formed by 9 Likert-type items (e.g. “Since the sanitary emergency caused by COVID-19 in Spain, have you been treated as if you were someone hostile, unhelpful or rude?”) with four response options (1 “never” – 4 “many times”). The different questions evaluated the presence of intersectional discrimination from the beginning of the alarm situation generated by the coronavirus. The higher the score the more discrimination suffered.

Internalized stigma

Internalized stigma was evaluated with two items adapted from the Internalized Stigma of Mental Illness (ISMI) scale (Boyd Ritsher, Otilingam & Grajales, 2003). The items (“Since the emergency situation generated by the coronavirus, have you avoided contacting people –in those cases permitted during lockdown– to avoid rejection?”; “Since the emergency situation generated by the coronavirus, have you felt that the people who are not in your situation are unable to understand you?”) were modified to evaluate intersectional internalized stigma, the self-stigma that can be generated by diverse conditions. These items refer to the alienation and social withdrawal dimensions taken from the original scale. It was evaluated with the same Likert-type scale as the one used to measure the intersectional perceived discrimination.

Social support

Social support was evaluated by means of the Multidimensional Scale of Perceived Social Support (EMAS) (Zimet, Dahlem, Zimet, & Farley, 1988), adapted to a Spanish version (Landeta & Calvete, 2002). The scale, made up of 12 Likert-type items with 7 possible responses (1 “totally disagree” to 7 “totally agree”), evaluates the levels of perceived social support, identifying where the support comes from and how it is perceived. The EMAS explores three possible sources of perceived social support –family (4 items), friends (4 items) and relevant people (4 items)–, and offers a full measure of social support.

Spiritual well-being

Spiritual well-being was assessed using the Spanish version of the Functional Assessment of Chronic Illness Therapy Spiritual Well-Being (FACIT-Sp12) (Cella et al. 1998). This test evaluates physical, family, functional and spiritual well-being, focusing in this questionnaire only on spiritual well-being with two dimensions: meaning and peace. Four items were selected from the scale focusing on these aspects. The answers were Likert type from 0 (nothing) to 4 (a lot). Higher scores indicate greater well-being.

Self-Compassion Scale (SCS)

Was used in its Spanish version (Garcia-Campayo et al., 2014; Neff, 2003). The scale evaluates how the subject usually acts towards himself in difficult moments in different dimensions. Here we explore with 6 items the following three: self-love, common humanity and mindfulness. The items are Likert type (1 to 5). Higher scores indicate more self-pity.

Sense of belonging

The sense of belonging to different work/study groups, friends, family and neighborhood or community was evaluated through four Likert-type items (1 much - 4 nothing) (Hernán Montalbán & Rodríguez Moreno 2017).