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Coronavirus disease 2019 (COVID-19) is a global epidemic of infectious diseases. As of February 26, 2023, the World Health Organization (WHO) had reported 757,264,511 confirmed cases of COVID-19 (1). To prevent the spread of coronavirus, the Chinese government implemented the most stringent anti-COVID regimes in the world, known as the “zero-COVID” policy. This policy included strict and targeted lockdowns, mass testing, isolation or quarantine, and other measures. On December 7, 2022, the Chinese government announced the end of the policy, which came rapidly and unexpectedly, causing panic among the population due to fear of infection and shortages of medicine supplies. Therefore, it is necessary to understand the mental health status of Chinese residents after the policy adjustment. Assessing the impact of the pandemic on people’s mental health has been identified as a public health research priority. Previous research has indicated that the COVID-19 epidemic has caused a rapid increase in the prevalence of anxiety and depression symptoms among the general population in China (2). However, there is limited research on people’s mental health after China released new COVID-19 rules. This study aimed to analyze the short-term depression and anxiety symptoms of the infected and non-infected populations after the abolition of strict pandemic control measures in China. This could provide evidence and suggestions for how to improve people’s mental health in the post-pandemic era.
From December 21–28, 2022, a cross-sectional online survey was conducted to investigate the symptoms of depression and anxiety among smartphone users. Convenience sampling strategies were used to recruit participants, who were electronically invited via WeChat, a Chinese social media APP. To increase the sample size, the link to the electronic questionnaire was shared to WeChat groups and Moments. Inclusion criteria: 1) Willing to participate in the study; 2) Living in Chinese mainland; 3) Able to use smartphones; 4) Knowing if he/she was infected. Exclusion criteria: 1) Participants with previously diagnosed mood disorders; 2) Incapable of completing the electronic questionnaire or unable to understand the questionnaire due to cognitive impairment or other diseases. Mature scales were used to investigate the psychological state, and data was cleaned according to the inclusion criteria and filling time (less than 120 seconds were excluded), and some data with logical errors were also excluded. A total of 5,310 electronic questionnaires were collected. According to the above criteria, 150 questionnaires were excluded, among which, 9 questionnaires had logical errors, 130 respondents were not sure whether they were infected with COVID-19, and 11 did not live in Chinese mainland. Finally, 5,160 (97.2% effective rate) valid questionnaires were included in this study. The questionnaire was composed of two parts. The first part collected sociodemographic information, such as gender, age, education level, marital status, employment status, average monthly personal income, and residence area. Participants were also asked to report whether they had chronic diseases before COVID-19 infection, how many injections of vaccinations they had completed at most, and whether they were infected. The second part focused on evaluating the depression and anxiety status of respondents over the past two weeks using the Patient Health Questionnaire-9 (PHQ-9) and the General Anxiety Disorder-7 (GAD-7). PHQ-9 presented respondents with 9 statements, each with a four-point scale and the total score ranged from 0 to 27. The total score of PHQ-9 was divided into 5 scales: 0–4, 5–9, 10–14, 15–19, and 20–27, corresponding to none, mild, moderate, moderately severe, and severe depression symptoms, respectively. Considering the small number of respondents in the latter two scales, this study combined them into moderately severe and above depression. GAD-7 had 7 items, and each was scored 0–3 points from “Not at all” (0 points) to “Nearly every day” (3 points). According to the total score of GAD-7, anxiety symptoms were grouped into four categories. A score of 0–4 represented no anxiety, 5–9 mild anxiety, 10–14 moderate anxiety and scores greater than 14 indicated possibly severe anxiety. The Chinese versions of these scales have been demonstrated to have good reliability and validity (3–4). In this study, the Cronbach’s alpha of PHQ-9 and GAD-7 were 0.899 and 0.944, respectively, indicating great internal validity. Continuous variables were summarized as mean±standard deviation or median (interquartile range). Categorical data were reported as n (%) and compared with Pearson’s Chi-square test or Fisher’s exact test. Ordinal logistic regression was used to assess the relationships between anxiety and depression symptoms and explanatory variables. PHQ-9 and GAD-7 scores were used as four-category dependent variables, and demographic information was used as independent variables. Odds ratios (ORs) and 95% confidence intervals (CIs) of independent variables were reported. All statistical analyses were performed using Stata statistical software (Version 15.0, StataCorp LLC, Lakeway Drive, College Station, Texas, USA). P-values <0.05 were considered statistically significant.
A total of 5,160 valid questionnaires were included in this study, of which 1,153 (22.3%) reported not being infected and 4,007 (77.7%) reported being infected. Of all participants, 1,536 (29.8%) were male and 3,624 (70.2%) were female. Most participants had an associate/bachelor degree or higher (83.8%). More than half of the participants were married (72.1%), employed (65.8%), had no history of chronic disease (83.1%), and had completed three doses of vaccination (80.8%), as shown in Table 1.
Characteristic Self-reported not infected (n=1,153) Self-reported infected (n=4,007) χ2 P-value No. of participants Percentage
(%)No. of participants Percentage
(%)Gender 11.197 0.001 Male 389 33.7 1,147 28.6 Female 764 66.3 2,860 71.4 Age (years) 69.625 <0.001 <30 296 25.7 837 20.9 30–39 170 14.7 934 23.3 40–49 284 24.6 1,172 29.2 50–59 260 22.5 708 17.7 ≥60 143 12.4 356 8.9 Education level 47.819 <0.001 High school education or lower 250 21.7 586 14.6 Associate/bachelor degree 644 55.9 2,199 54.9 Graduate degree 259 22.5 1,222 30.5 Marital status 22.078 <0.001 Single 303 26.3 881 22.0 Married 772 67.0 2,947 73.5 Others* 78 6.8 179 4.5 Employment status 75.049 <0.001 Employed 639 55.4 2,758 68.8 Retired 209 18.1 505 12.6 Students 221 19.2 499 12.5 Others 84 7.3 245 6.1 Monthly personal income (CNY†) 94.531 <0.001 <3,000 362 31.4 810 20.2 3,000–5,000 228 19.8 697 17.4 5,000–10,000 296 25.7 1,076 26.9 10,000–15,000 152 13.2 797 19.9 >15,000 115 10.0 627 15.6 Residence area 42.274 <0.001 Urban 992 86.0 3,698 92.3 Rural 161 14.0 309 7.7 Region 10.346 0.006 East 841 72.9 3,088 77.1 Central 127 11.0 335 8.4 Western 185 16.0 584 14.6 History of physical illness 0.250 0.617 Chronic disease 200 17.3 670 16.7 Healthy 953 82.7 3,337 83.3 Vaccination 8.909 0.063 0 46 4.0 167 4.2 1 11 1.0 32 0.8 2 100 8.7 386 9.6 3 922 80.0 3,246 81.0 4 74 6.4 176 4.4 * Other marital statuses include divorced, widowed, cohabiting, and remarried.
† 10,000 Chinese Yuan≈1,476 US dollars in 2023.Table 1. Demographic characteristics of participants (n=5,160).
The mean PHQ-9 and GAD-7 scores were 6.1±5.3 and 3.1±3.9, respectively. The median scores of PHQ-9 and GAD-7 were 5 (2 to 9) and 2 (0 to 5), respectively. As shown in Table 2, 2,872 (55.7%) participants may have had depression symptoms and approximately one-third (30.1%) may have had anxiety symptoms. The Chi-square test revealed a significant difference in depression (P<0.001) between infected and non-infected participants, but no difference in anxiety (P=0.066) was observed.
Symptoms Self-reported not infected Self-reported infected χ2 P-value No. of participants Percentage
(%)No. of participants Percentage
(%)PHQ-9 99.398 <0.001 Normal 660 57.2 1,638 40.9 Mild depression 322 28.0 1,520 37.9 Moderate depression 111 9.6 494 12.3 Moderately severe and above depression 60 5.2 355 8.9 GAD-7 7.176 0.066 Normal 799 69.3 2810 70.1 Mild anxiety 285 24.7 888 22.2 Moderate anxiety 52 4.5 214 5.3 Severe anxiety 17 1.5 95 2.4 Abbreviation: PHQ-9=patient health questionnaire-9; GAD-7=generalized anxiety disorder-7. Table 2. Symptoms of depression and anxiety among participants.
The results of Chi-square test or Fisher’s exact test of different factors of depression and anxiety symptoms among participants revealed that most factors were statistically significant in predicting the risk of depression and anxiety (P<0.05). Results of ordinal logistic regression of PHQ-9 showed that gender (OR=1.150, 95% CI: 1.023–1.293) was a risk factor for depressive symptoms. Age over 50 (OR<1), being married (OR=0.748, 95% CI: 0.602–0.931), having a personal monthly income of more than 5,000 RMB (OR<1), no history of chronic diseases (OR=0.740, 95% CI: 0.632–0.865), completion of four doses of vaccinations (OR=0.562, 95% CI: 0.392–0.806), and not being infected (OR=0.543, 95% CI: 0.476–0.619) were protective factors for depression, as shown in Table 3, which also displays the effect of variables on GAD-7 scores by ordinal logistic regression. Participants aged 50 or over were less likely to experience anxiety symptoms compared to those under 30 (OR<1). Student status (OR=0.653, 95% CI: 0.477–0.895), having a monthly personal income of more than 5,000 CNY (OR<1), having no history of chronic disease (OR=0.594, 95% CI: 0.497–0.711), and having completed four doses of vaccinations (OR=0.561, 95% CI: 0.371–0.848) were protective factors for anxiety.
Variables PHQ-9 GAD-7 OR (95% CI) P-value OR (95% CI) P-value Gender Male 1.00 (Ref) 1.00 (Ref) Female 1.150 (1.023, 1.293) 0.019 1.029 (0.898, 1.178) 0.684 Age (years) <30 1.00 (Ref) 1.00 (Ref) 30–39 0.972 (0.765, 1.236) 0.820 1.259 (0.963, 1.648) 0.093 40–49 0.792 (0.617, 1.018) 0.068 0.867 (0.652, 1.152) 0.324 50–59 0.563 (0.427, 0.743) <0.001 0.568 (0.412, 0.785) 0.001 ≥60 0.590 (0.408, 0.855) 0.005 0.617 (0.400, 0.952) 0.029 Education level High school education or lower 1.00 (Ref) 1.00 (Ref) Associate/bachelor degree 1.027 (0.858, 1.230) 0.769 1.064 (0.867, 1.306) 0.552 Graduate degree 1.079 (0.870, 1.338) 0.488 1.046 (0.818, 1.338) 0.720 Marital status Single 1.00 (Ref) 1.00 (Ref) Married 0.748 (0.602, 0.931) 0.769 0.827 (0.647, 1.058) 0.131 Other 0.957 (0.695, 1.318) 0.488 1.017 (0.710, 1.458) 0.925 Employment status Employed 1.00 (Ref) 1.00 (Ref) Retired 0.814 (0.631, 1.050) 0.113 0.825 (0.606, 1.123) 0.221 Students 0.784 (0.591, 1.039) 0.090 0.653 (0.477, 0.895) 0.008 Others 1.008 (0.788, 1.289) 0.951 1.009 (0.768, 1.325) 0.947 Monthly personal income (CNY) <3,000 1.00 (Ref) 1.00 (Ref) 3,000–5,000 0.819 (0.661, 1.015) 0.069 0.791 (0.622, 1.006) 0.056 5,000–10,000 0.740 (0.589, 0.931) 0.010 0.671 (0.519, 0.867) 0.002 10,000–15,000 0.677 (0.526, 0.872) 0.003 0.571 (0.429, 0.760) <0.001 >15,000 0.636 (0.484, 0.835) 0.001 0.488 (0.356, 0.668) <0.001 Residence area Urban 1.00 (Ref) 1.00 (Ref) Rural 0.877 (0.721, 1.065) 0.185 0.914 (0.733, 1.140) 0.427 Region East 1.00 (Ref) 1.00 (Ref) Central 0.960 (0.795, 1.160) 0.674 0.996 (0.802, 1.236) 0.969 Western 1.105 (0.952, 1.282) 0.188 1.126 (0.953, 1.331) 0.164 History of physical illness Chronic disease 1.00 (Ref) 1.00 (Ref) Healthy 0.740 (0.632, 0.865) <0.001 0.594 (0.497, 0.711) <0.001 Vaccination 0 1.00 (Ref) 1.00 (Ref) 1 1.149 (0.615, 2.146) 0.663 0.951 (0.477, 1.895) 0.887 2 0.982 (0.720, 1.339) 0.908 0.906 (0.642, 1.278) 0.573 3 0.911 (0.696, 1.191) 0.494 0.802 (0.597, 1.079) 0.145 4 0.562 (0.392, 0.806) 0.002 0.561 (0.371, 0.848) 0.006 Infection Infected 1.00 (Ref) 1.00 (Ref) Not infected 0.543 (0.476, 0.619) <0.001 1.030 (0.891, 1.191) 0.688 Abbreviation: OR=odds ratio; CI=confidence interval; CNY=Chinese Yuan. Table 3. Ordinal logistic regression of the patient health questionnaire-9 (PHQ-9) and the generalized anxiety disorder-7 (GAD-7) scales.
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This study examined the prevalence of anxiety and depression among participants in China following changes to epidemic prevention and control policies during the ongoing COVID-19 pandemic. Results indicate that mental health is significantly impacted by the pandemic, and it is important to remain mindful of the mental health of vulnerable populations, both those infected and those who remain uninfected, as the pandemic continues.
Compared to existing studies conducted when “zero-COVID” policy was implemented, the percentages of participants with depression and anxiety were slightly higher in this study (5). Many people were unprepared for the sudden change in the epidemic prevention and control policy, leading to worries about infection, virus mutation, and re-outbreak of COVID-19, which resulted in negative emotions for many. Compared to Australia (6), the percentages of respondents with depression in this study were slightly higher, while anxiety was lower. The mean score of PHQ-9 was close to the scores of four European countries, and the mean score of GAD-7 was lower than those countries (7). Consistent with the findings of Lei et al. (8), we found that participants infected with COVID-19 had significantly more depressive symptoms than the uninfected. However, a large portion of the uninfected also experienced depression symptoms.
As for influential factors of mental health, we found that respondents who were older, had higher incomes, had no history of chronic diseases, and had completed vaccinations experienced fewer symptoms of depression and anxiety. Older adults were less likely to experience symptoms of depression and anxiety compared to younger adults, which is consistent with findings from an Australian survey and a global online survey that showed younger people were more prone to stress, depression, and anxiety (9). This may be related to the fact that the elderly were better able to cope with stress and worried less about working and financial burdens. Higher incomes corresponded to higher anti-risk ability and the possibility of obtaining better medical resources, so participants with higher incomes were less likely to have psychological problems (10). People with chronic diseases were more susceptible to infection and mental illness, so attention should be paid to the health management of chronic disease patients. It is recognized that COVID-19 vaccines can effectively reduce the risk of infection, so older adults who may face a higher risk of complications from vaccine-preventable diseases should stay up to date on recommended vaccines. Valentina et al. (11) found that women suffered the worst short and long-term psychological problems, which was also supported by this study. Therefore, it is imperative to consider the effects of the pandemic on women’s mental health during the aftermath of COVID-19. Students were less likely to experience anxiety than employed people, which may be due to the heavy burden from work and family faced by workers.
This study has some limitations. The sample may not be representative of the broader population, as a large proportion of participants had received higher education and were employed. Additionally, since this was a cross-sectional study, it is not possible to determine the effect of epidemic prevention and control policy adjustments on people’s psychological health over time. Therefore, further longitudinal studies are needed to examine the long-term effect of the pandemic on mental health.
Following the conclusion of China’s “zero-COVID” policy, individuals continued to experience significant symptoms of depression and anxiety. Those who were young, female, unvaccinated, had low incomes, and had a history of chronic illnesses were more likely to experience mood disorders. To protect the mental health of these vulnerable populations and promote health equity, sustainable, effective, and tailored community interventions should be implemented in the future to address these issues.
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No conflicts of interest.
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The authors would like to acknowledge all the participants for their support and work for this study.
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