An Internet Investigation of Mental Health Status of 1144 Different Status Identities in South China during Outbreak of COVID-19

Background At the end of 2019, the Coronavirus disease 2019 (COVID-19), with highly infectious, transmits rapidly. So it has caused people panic to a certain degree. Methods This cross-sectional study performed via an online survey run from January 30 to March 30, 2020. 1144 people in South China (287 of level 1 population, 121 of level 2 population, 160 of level 3 population, 576 of level 4 population ) were investigated. GAD-7 scale, PHQ-9 scale, and PSS-10 scale were used to evaluate the mental health status of different populations. Results Among 1144 subjects, the average GAD-7 score was 4(1,8), the average PHQ-9 score was 4(1,9), and the average PSS-10 score was 16(11,19). There were statistically signicant differences in the scores of GAD-7 (H = 15.235, P <0.01), PHQ-9 (H = 9.265, P = 0.026), and PSS-10 (H = 8.435, P = 0.049) among different levels of population. In the score of GAD-7: The anxiety degree of the level 1 population is higher than that of the level 2 population and the level 4 population. The difference between the two pairs is statistically signicant (Z = -2.932, -4.012, -2.949, P <0.005). There are signicant differences in items of“becoming easily annoyed or irritable”, "seemingly terrible things will happen"(Z = -3.399 ~ -2.055, P <0.005); Score of PHQ-9: The depression degree of the level 1 population and the level 2 population is higher than that of the level 4 population, and the difference between the two pairs is statistically signicant (Z = -3.38, -2.682, P <0.005). There are signicant differences in items of "dicult to fall asleep or not awake", "feeling depressed" and other related items (Z = -2.885 ~ -2.003, P <0.005); Score of PSS-10: The stress degree of the level 3 population is higher than that of the level 1 population and the level 4 population (Z = -3.693 ~ -2.702, P <0.005). There are signicant differences in items of "feel condent", "life are as expected", "the ability to control anger", "the things are all under control" and other related items (Z = -4.782 ~ -2.102, P <0.005). Conclusion There are differences in the effects of COVID-19 on the mental health of people with different identities. Appropriate psychological interventions should be provided for different populations in combination with their mental health status. 7-item Generalized Anxiety Disorder scale (GAD-7) was used to assess the severity of symptoms of anxiety. The results of GAD-7 are as follows: normal ( (cid:0) 5), severe (15–21) anxiety; 9-item Patient Health Questionnaire (PHQ-9) was applied to assess the severity of symptoms of depression. The results of PHQ-9 are moderate (10–14), moderately severe (15–19) and severe (20–27) depression; 10-item Perceived Stress Scale (PSS-10) was used to assess the severity of sy 10 are as follows: mild (0–14), moderate (15–25), moderately severe (26–31) and severe (32–40) stress.


Background
Coronavirus Disease 2019 (COVID- 19), named by the World Health Organization (WHO) on January 2020 [1], soon afterwards has been declared an epidemic so as to increase the awareness of its severity globally [2]. At present, there are no speci c medicine as well as treatments for COVID-19, only supportive care is provided to the patients [3]. In addition, COVID-19 is a highly infectious disease that can be transmitted person-to-person, people who was infected by COVID-19 can be asymptomatic [4]. As the disease still exists and complex elements continue puzzling us, human beings should face this crisis vigilantly and have a long way to go. To some extent, this horrible disease has aroused panic for the population [5].
Fighting against crucial challenges during COVID-19 outbreak, people have undergone an emergency, which may develop different psychological issues respectively. Accordingly, as for frontline health care workers in COVID-19 epidemic [6,7], overwhelming workload, inadequate equipment and social support, as well as high risk of infection may lead to their urgent and long-term mental problems. What has been approved in the previous experience was that, health care workers in the Emergency Department from Hong Kong during SARS outbreak felt distress because of loss of control, fear of personal health and the spread of the virus [8]. In spite of distress, depression, anxiety, insomnia and other psychological problems would appear on medical staff when there is an epidemic outbreak. Con rmed patients, however, may experience fear and anxiety due to the severity of the disease, and the infectious symptoms of COVID-19 should be to blame because they may cause any other disturbances, like insomnia, distress and so on. Similarly, since the epidemic is still uncertain, and the quarantine environment is somehow scary [9], suspected patients and those who isolated would develop fear, stress, hypochondriasis and other mental issues.
Of note, in order to successfully control the infection of COVID-19, strict measures like quarantine is of utmost signi cance. However, quarantine and home staying could bring out unexpected results. During staying home, the individuals would adopt psychological distress, frustration and boredom due to long duration of quarantine, fear of being infected and having insu cient information as well as protective supplements [10]. As for the general public, correct and adequate information was needed, but they often searched for overwhelming information, and some of them received rumors, which may lead to anxiety and fear among the population [11,12].
To provide mental services to the individuals speci cally, populations are categorized into 4 levels [11,13], according to the degree to which the population is affected by COVID-19: Level 1 population consists of con rmed patients with COVID-19, frontline health care workers, etc.; Level 2 population includes isolated mild-symptoms patients with COVID-19 or suspected COVID-19 patients; Level 3 population contains people related to the Level 1 or Level 2 population, including relatives, friends etc.; and Level 4 population mainly involves the susceptible and the general public.
If preventive measures were not taken immediately, mental issues may lead to serious psychological disorders [14,15]. Therefore, agencies from different elds spared no efforts in carrying out various forms of prompt interventions all over China. First of all, government authorities, especially health authorities like the NHC, have adopted some psychological intervention and mental service guidelines so as to make it more regularized [11]. According to the Principle, social power, 24-hour psychological assistance hotlines, clinical psychological assistance teams as well as psychological expert teams should be organized and coordinated by the government [16]. The Principle has called for every quali ed mental health associations and academic agencies take the responsibilities to set up professional expert teams, provide mental services, establish psychological assistance hotline and conduct guidelines and instructions [13]. During the COVID-19 outbreak, it is reported that there were at least 29 guidelines and instructions established to direct mental health services nationwide between January 26th and February 20th [11]. Compared with the SARS outbreak in 2003, online mental health services are more convenient and accessible for population recently due to the promulgation of internet services and smart phones. Online mental health surveys related to COVID-19, for example, were conducted to collect information about public mental issues so as to understand the latest situation of people with various identities [17]. Moreover, online mental health education for the general public as well as online mental consulting for those who were in need have been released to provide targeted services. Nevertheless, online services play a signi cance role to solve public psychological issues during COVID-19 [17].
Though telephone-, internet-and application-based as well as o ine psychological health services have been conducted throughout China during COVID-19 epidemic, evidence-based assessments were limited [18], most of which were mostly targeting health care workers [19] and vulnerable populations such as older adults [20], mental illness [21] and Chinese students studying overseas [22].
The current study would represent mental health status and psychological health survey to people in different four levels in China rstly. Researches about mental health status and mental health interventions related to COVID-19 for population with different identities are de cient. To address the gap, participants were selected from 4 different levels illustrated above in the current study. The magnitude of anxiety, depression and stress symptoms were evaluated to examine the mental health status of populations, which would be helpful to provide evidence to draw up constructive and speci c measurements to promoting the mental well-being for each de ned group facing the challenge in the epidemic.

Participants
This study is a cross-sectional, survey-based research, in which snowball sampling was employed to recruit participants with different identities in South China. An online survey was publicized to the individuals and they were advocated sending it to other people. 911 individuals associated with COVID-19 could be searched for via the WeChat o cial account of the hospital, WeChat and the hospital website. Online questionnaire are addressed based on Questionnaire Star. Among the questionnaires, 1144 of which are valid, and the sampling e ciency is 92.4%. Enrollment criteria: participants should (1) nish the questionnaire independently with relevant educational attainments as well as physical and mental health; and (2) take part in this research voluntarily.
Exclusion criteria: individuals who were (1) patients with schizophrenia, bipolar disorder, and other severe mental illnesses or personality disorder; or (2) patients with cognitive dysfunction or severe physical illnesses that can not complete the survey were excluded. This project has been approved by the Ethics Committee of A liated Brain Hospital of Guangzhou Medical University.

Quality Control
Online questionnaire was adopted in this research. To guarantee the e ciency of the data, participant in the same IP address can only accomplish the survey once, and questionnaires from IP addresses outside South China were removed. Only completed questionnaires can be submitted, and real-time backstage monitoring is operated.

Differences in Total Scores of Anxiety, Depression and Stress among People with Different Identities
As the Table 2 has shown, the scores of three scales of 1144 participants were: anxiety 4(1,8), depression 4(1,9) and stress 16 (11,19). As what is shown in Table 3   3.3 Item Analysis of GAD-7, PHQ-9 and PSS-10 Item analysis was conducted to further investigate the effect of factors from GAD-7, PHQ-9 and PSS-10, exploring the various factors in uencing anxiety, depression and stress among all levels. As shown in Table 4, there are 7 items in GAD-7, of which there was a statistically signi cant difference in items "Feeling nervous, anxious, or on edge", "Not being able to stop or control worrying", "Being so restless that it's hard to sit still", "Becoming easily annoyed or irritable", "Feeling afraid as if something awful might happen" (Z =-3.399~-2.051, P = 0.001 ~ 0.040). According to Table 5, there are 9 items in PHQ-9, of which there was a statistically signi cant difference in items "Little interest or pleasure in doing things", "Feeling down, depressed, or hopeless", "Trouble falling or staying asleep, or sleeping too much", "Trouble concentrating on things, such as reading the newspaper or watching television", "Thoughts that you would be better off dead or of hurting yourself in some way" (Z =-2.736~-2.003, P = 0.004 ~ 0.048).    Table 6, there are 10 items in PSS-10. There was a statistically signi cant difference in "Feeling unable to control the important things in life', "Feeling con dent about your ability to handle personal problems", "Feeling things were going on your way", "Finding you couldn't cope with all the things you have to do", "Being able to control irritations in life", "Feeling you were on the top of things", "Being angered because of things that were outside of control", "Feeling di culties were piling up so high that couldn't overcome" (Z =-4.782~-2.087, P = 0.001 ~ 0.037 or P 0.001).  [17]. COVID-19 as an uncertain and severe public health crisis, would crush individuals physically and psychologically. Scholars has approved that effective mental interventions may reduce one's anxiety and depression symptoms during disasters [28].
Consequently, interventions such as psychological counseling should be carried out to promote mental health condition during the epidemic.

Anxiety Symptoms among People with Different Identities
Anxiety symptom of Level 1, Level 2 and Level 4 population present a descending gradient array. As for Level 3 population, there is a big difference on anxiety symptom and depression symptom from other groups, some of which are approximately the same with that of Level 1 and Level 2 population, while some of which are quite similar to that of Level 4 population, suggesting that anxiety and depression symptom of Level 3 population is indistinguishable from other levels. Of note, this sort order is consistent with ripple effect [29]. In terms of ripple effect, the degree of anxiety will move from the center to the layer of risk event, people in the center report highest anxiety scores. For example, mainly consisting of con rmed patients and frontline health care workers, Level 1 population is exposed to the high risk environment, whose mental well-being can be ruined because of material shortages and infection. Thus, they reported saliently high rate of anxiety, inferring that living environment may account for the result of such effect. As for Level 2 population, the quarantined individuals or suspected patients would be likely to worry about their physical and mental health. They would unnecessarily apply over-interpretation to their harmless symptoms, which arouse numerous anxious emotion. Compared with Level 1 and Level 2 population, health conditions of Level 4 population were better, as this group contained the general public and the susceptible. Though a lower degree of anxiety appeared among Level 4 population, limited daily activities, endless home quarantine and protective equipment shortages still affect their lives.

Depression Symptoms among People with Different Identities
Coincidentally, ripple effect can also explain the result of depression symptom in this study. No signi cance was found on depression between Level 1 and Level 2 population, but both scores are higher than that of Level 4 population. Members in both groups have a connection with the reservoir of infection directly or indirectly, that is to say, they take greater risks similarly than any other individuals. Facing with the novel and even unknown virus, both groups perform upset, negative and dragged emotion, which re ects higher scores of depression. Having isolated at home for a long time, Level 4 population produces depression symptoms as expected.

Stress Symptoms among People with Different Identities
Stress symptoms show a decline trapezoidal arrangement among Level 3, Level 1 and Level 4 population, which can be clari ed by psychological typhoon eye effect. During the risk event, people who are at the core may show a lower degree of stress, while those who are away from the core present higher stress symptoms. An important nding in the current research was that, compared with Level 3 population, Level 1 population is closer to the risk event in relative distance. Due to the closer relative distance, members in Level 1 population show lower stress symptoms, which approves the result of a previous study.
Though Level 1 population reports lower risk of stress, being exposed to the critical circumstance makes it possible for them to develop stress emotion. What should be focused on was that, there is an intimate relationship among people in Level 3 population and Level 1 or Level 2 population, the close relatives or friends would worry about the health status of their acquaintances as well as be afraid of being infected on the other hand. Stress symptom of the individuals belonged to Level 4 population is the lowest, because they will not be infected directly as long as they adopt appropriate and adequate protections.

Speci c Mental Health Issues among People with Different Identities
Anxiety problems that becoming easily annoyed or irritable (items 6 in Table 4) and Feeling afraid as if something awful might happen (items 7 in Table 4) are more obvious on Level 1 and Level 2 population than Level 4 population. People may become anxious and irritable emotionally, and they will have negative predictions of the future, who may be afraid of the coming future. Another key discovery of the recent study is people from Level 1 and Level 2 population are more likely to suffer from the depression problems which Feeling down, depressed, or hopeless (items 2 in Table 5) and Trouble falling or staying asleep, or sleeping too much (items 3 in Table 5), compared with the individuals of Level 4 population. Similarly, stress problems of Level 4 population are less mild than that of Level 1 and Level 3 population. The latter reports more di culties in establishing self-esteem, controlling or predicting personal affairs and controlling anger emotion. Having negative prediction of the future is quite common among those people, they lost faith in coping with personal problems, and they do not believe they have the ability to control their life and emotion.

Intervention Strategies of Mental Health for Social Agencies during COVID-19
As the epidemic continues to threaten the mental health of the public, the whole society should work together providing forceful measures during the epidemic [30]. Firstly, authorities or departments concerned should conduct epidemiological investigations frequently, mastering the exact information and dynamic changes of mental health status of all levels [31]. Of note, discerning high-risk population and providing timely psychological crisis interventions to prevent extreme personal and social incidents (e.g. Suicide and compulsion) are of utmost signi cance [32]. In addition, professional as well as systematic mental health services should be strengthened and integrated under the guidance of national authorities. A better mental health system is still developing, and this is also a challenge for us to face with [33]. Therefore, only when a superior system has built up, people can bene t it from greater mental health services.
Secondly, health agencies should adopt related mental health surveys to understand the psychological needs among the general public, which can be vital to arrange targeted interventions. Moreover, related psychological associations and academic societies should take the responsibilities for immediate and quali ed services, such as mental assistance hotline, expert teams supporting high risk zones, psychological consulting and any other accessible means of services. Though COVID-19 has been eased effectively in China, there are still individuals stricken with serious mental disorders [33]. Individuals suffering from severe mental trauma have a high hazard to develop PTSD [34], but an earlier study showed that psychological interventions are bene cial to reduce anxiety and depression during disasters, and is good for them to develop personal strategies for coping with crisis [28].
Thirdly, basic living supplies and correct information should be equipped for the public by the government. According to a guideline conducted to help patients adjust to the mental effects of quarantine and isolation, insu cient supplies and inadequate information are main stressors during quarantine [10,12]. In the beginning of the COVID-19 outbreak, the supply of facial masks, medical protective coveralls and other protective materials as well as some basic supplies fell short of demand, which lead to panic in the population. Later on, as production capability has gradually resumed, the supply recovery enables people to decrease psychological issues. Some scholars suggested that the receiving health information with higher satisfaction may lead to a decreased mental impact of the outbreak and decreased levels of stress, anxiety, and depression [35]. Therefore, government and health authorities should guarantee basic materials and protective equipment to every community, correct and timely epidemic information and quali ed health care knowledge especially mental health education should be popularized.

Speci c Interventions of Mental Health targeted People with Different Identities
Level 1 population, because frontline health care workers [38] and con rmed patients are experiencing dramatic high risk exposure, and they may not enable to seek for psychological aid proactively. Meanwhile, some hospitals have set up a relaxing room for the medical staff to isolate themselves temporarily and adopted some ways to keep in touch with their relatives so as to maintain social support [38].
With regard to Level 2 population, daily life, work and outing activities are limited due to the long-term quarantine, which leads to the serious consequence of mental stress to the innocent residents. Obviously, to adjust this psychological imbalance, those whom isolated should guarantee a regular healthy life style [39], ameliorate sleep [40] and seek for social support [41] (e.g. Intimate relationships or professional psychological assistances) if necessary. Related agencies should identify people in this category, offering some basic and necessary mental assistance can be helpful. The psychological assistance hotline will be very accessible for those quarantined as they cannot go anywhere.
Besides, there were some intervention strategies for Level 3 population. As reported previously, people in this category are mainly concerned about the health condition of their risky relatives and friends, who may be in a seriously stressed state. To avoid the unexpectedly worse situation happening, they should grasp some credible scienti c information about COVID-19, learn to aware and accept all the emotional and physical responses. They may be able to decrease stress with the assistance of taking relaxation exercise [42] (e.g. Music therapy and abdominal respiration) and professional mental aids.
Level 4 population, the general public and the susceptible, should stabilize emotion, keep a healthy lifestyle, promote interpersonal relationships and avoid information overload. Absorbing overwhelming information could sometimes make one anxious and even promote anger, as some messages are not real, and negatively in uence our cognition. Additionally, mental health education cannot be ignored, which should be carried out by quali ed institutions regularly.

Limitation
The current research is a cross-sectional study to assess mental health status of people from four different levels, which provides some evidence for the longitudinal study of personal mental health after the epidemic. But there are several limitations in this study. Firstly, the sample size of this study is limited. Secondly, anxiety, depression and stress symptoms on all levels were included in the current study, but new evolutions of COVID-19, how people grasp relevant information as well as sleep and eating problems of affected people were not included in our research. Lastly, because of the COVID-19 outbreak, people were informed to stay home and avoid crowed places, con rmed patients, suspected individuals and health care workers were isolated. Therefore, online survey was conducted, and snowball sampling took the place of simple random sampling in our research, which may lead to an unrepresentative sample. It is suggested that improving sampling methods and evaluation of mental impacts should be included in the further research.

Conclusion
Our Ethics approval and consent to participate was given by: Ethics Committee of A liated Brain Hospital of Guangzhou Medical University. Obtaining informed consent from participants was part of the screening process. Participants will attend an information session where they will be provided verbal and written information of the research project. If they agree to participate they will provide signed informed consent and be formally screened to assess in-and exclusion criteria.

Consent for publication
Not Applicable.

Availability of data and material
Data and materials will be available at the completion of this study.

Competing interests
The authors declare that they have no competing interests.

Funding
The Guangdong Natural Science Foundation, China (2015A030313800 to Hongjun Peng) supported the design of the study. The Guangzhou municipal key discipline in medicine for Guangzhou Brain Hospital (GBH2014-ZD04 to Hongjun Peng) supported the data collection of the study. The Science and