DEPRESSION, ANXIETY, PERCEIVED AND POST-TRAUMATIC STRESS, AND THE USE OF ALCOHOL DURING THE COVID-19 PANDEMIC IN ESTONIA FROM SPRING TO AUTUMN IN 2020: A LONGITUDINAL STUDY.

• Author: Kulbin, Karel

1. Introduction

   Many countries face challenges in response to the COVID-19 pandemic. The countries have applied different measures in fighting the new Coronavirus and its consequences. Public health response decisions were made under scientific uncertainty around the infectiousness and natural history of COVID-19 to protect the population and avoid overwhelming the health system. Since the beginning of the pandemic in 2020, mental health has been addressed as one of the research priorities (Holmes et al. 2020). As yet, we lack information on the response in this pandemic. A lot of the interest has focused on short-term concerns, but the mental health impact of the pandemic is likely to last much longer than the physical health impact (Kousoulis et al. 2020). Thus, it is important to document, if and what changes there have been in people's mental health since the beginning of and during the ongoing pandemic. The situation regarding the COVID-19 pandemic in different countries has changed quickly due to changing case numbers, changing governmental restrictions (Hale et al. 2020), habituation or change in media coverage. This indicates that mental health consequences may have changed also rapidly and differed by countries.

   The reliable quantifications of the impact that the pandemic has had on mental health comes from a number of longitudinal cohort studies which have collected data from the same participants before and during the pandemic. Daly et al. (2020) found in a large nationally representative sample, that non-specific mental health problems increased substantially as the pandemic emerged in the UK and sustained throughout April to June 2020. Similarly, Pierce et al. (2020) found that by April 2020 there was an overall increase in mental distress in people aged 16 years and older in the UK compared with in the previous year. Mental distress did not affect all demographic groups equally - being young, a woman, and living with (especially preschool age) children had a particularly strong influence on the increase of mental distress during the first phase of the pandemic.

   Another study from the UK has shown on a longitudinal population cohort that anxiety symptoms increased and wellbeing decreased during the lockdown of COVID-19 (April/May 2020) compared to pre-pandemic levels, particularly in young people (Kwong et al. 2020). Yet, they did not find clear evidence that prevalence of depressive symptoms had increased during the initial phase of COVID-19 from pre-pandemic levels. Gonzalez-Sanguino et al (2021) conducted a longitudinal study starting after one week into the state of emergency in Spanish population. They found that depressive symptoms increased throughout the confinement and did not drop to previous levels with de-escalation on the restrictive measures by the end of May 2020. On the other hand, the symptomatology of post-traumatic stress disorder (PTSD) showed a reduction with the lifting of the lockdown. Regarding the symptoms of anxiety, they found no significant changes between the three evaluations, from March to the end of May 2020. Their results also indicated that mental health of young people and females was more affected during the first stage of pandemic.

   Similar studies have monitored their longitudinal samples further into the summer and/or early fall 2020, which has added mixed evidence regarding the longer lasting effects of pandemic on mental health. A longitudinal study of US adults also reported an initial increase in distress when pandemic emerged, but distress reduced close to pre-pandemic levels by June 2020 (Daly and Robinson 2021). Another study in England analyzed the trajectories of disorder-specific symptoms of anxiety and depression over the 20 weeks after lockdown (Fancourt et al. 2021). Their results showed that the highest levels of depressive and anxiety symptoms occurred in the beginning of lockdown but declined fairly rapidly. Both studies suggested that possibly individuals adapted to circumstances and resilience in mental health may have occurred in response to the pandemic (Daly and Robinson 2021, Fancourt et al. 2021). Bendau et al. (2021) conducted a research involving four data collection waves from March to June 2020 in Germany. They indicated that specific COVID19-related anxiety and the average daily amount of preoccupation with the pandemic decreased continuously over the four waves. Unspecific anxiety and especially depressive symptoms showed a slighter decrease on average. Controversially, a study in Austrian representative sample (Pieh et al. 2021) does not support these trends and found that detrimental mental health consequences persisted several months after the outbreak of pandemic. The prevalence of clinically relevant symptoms of depression, anxiety, or insomnia had not decreased six months after the outbreak of pandemic (by September 2020) in Austrian sample. albeit they documented a slight trend toward improvement in perceived stress and well-being during the same period of time.

   Perhaps the strongest evidence on the topic is lately presented in a systematic review and meta-analysis by Robinson et al. (2021). Their meta-analysis across 65 longitudinal cohort studies showed a statistically small overall increase in mental health symptoms, which was most pronounced during the first two months of the pandemic (March-April 2020), before generally decreasing close to pre-pandemic levels by mid-2020. More specifically, the increases in depressive symptoms tended to be larger and remained higher past the early phases of the pandemic, compared to anxiety symptoms, non-specific general mental health functioning and well-being. Detrimental consequences in mental health were observed across most population subgroups and change in mental health symptoms did not differ based on age. Contrary to predictions, their meta-analysis showed no evidence of a worsening of symptoms among samples with a pre-existing mental health condition. Somewhat interestingly, they observed similar patterns of increase in mental health symptoms both in North American and European samples (very few samples were included in their study from elsewhere). They found no evidence that country-level data (number of COVID cases/deaths; stringency of government measures) explained heterogeneity between samples. It seems plausible for the first stage of the pandemic, while governments in North America and Europe applied relatively similar restrictive measures with similar timings, regardless of largely differing COVID-19 case numbers, hospitalizations and deaths (Hale et al. 2020). Robinson et al. (2021) concluded that the first wave of pandemic (Spring 2020) may not have caused a long-lasting mental health crisis and the initial consequences were probably followed by a period of psychological adaptation and resilience. However, they call for continued mental health monitoring, given that there have been second waves of rapid increase of COVID-19 infection in many countries during late 2020 or early 2021.

   A review of psychological stressful experiences and alcohol intake reports that stress is associated with increased risk for alcohol use, alcohol-related problems, and alcohol use disorders (Keyes et al. 2011). Recent COVID-19 studies reported some increase in alcohol use due to higher levels of stress, anxiety, and depression symptoms (Stanton et al. 2020, Oksanen et al. 2020, Newby et al. 2020, Ahmed et al. 2020). The Finnish longitudinal study outlines that previous hazardous drinkers tended to increase their drinking further (Oksanen et al. 2020). Being at home/quarantined, lack of routine and symptoms of mental disorders were associated with increase in alcohol use. Excessive alcohol use can in turn lead to or worsen existing mental health problems, such as anxiety or depression. However, the cross-sectional online European alcohol and COVID-19 survey, conducted between April 24 and July 22 of 2020, reported a lowered level of consumption (except in Ireland and UK) (Kilian et al. 2021). Declines in consumption were less marked among those experiencing distress. The findings suggest that both reduced physical and financial availability of alcohol may have affected alcohol consumption.

   As there are two opposing views on whether alcohol consumption will increase during the COVID-19, it is meaningful to monitor how this public health crisis affects alcohol consumption. These results will provide more evidence of changes in alcohol use and associated consequences during the COVID-19 pandemic.

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