Impact of SARS-CoV-2 Outbreak on Physical and Mental Health, Psychological Distress, and Suicidal Ideation, and the Mediating Role of Stressors

Keita Kiuchi ^1,*, Katsumasa Kishi ², Kanto Araki ³

1. Research Center for Overwork-Related Disorders, National Institute of Occupational Safety and Health, Kawasaki, Japan

2. Practical Psychology Institute, LLC, Kawasaki, Japan

3. Center for Asian and Pacific Studies, Seikei University, Musashino, Japan

* Correspondence: Keita Kiuchi

Academic Editor: Soo Liang Ooi

Received: December 23, 2020 | Accepted: March 10, 2021 | Published: March 17, 2021

OBM Integrative and Complementary Medicine 2021, Volume 6, Issue 1, doi:10.21926/obm.icm.2101010

Recommended citation: Kiuchi K, Kishi K, Araki K. Impact of SARS-CoV-2 Outbreak on Physical and Mental Health, Psychological Distress, and Suicidal Ideation, and the Mediating Role of Stressors. OBM Integrative and Complementary Medicine 2021; 6(1): 010; doi:10.21926/obm.icm.2101010.

© 2021 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Introduction

Studies have been published in many countries regarding the psychological impact of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak. An early-stage review of four cross-sectional studies from China suggests that anxiety, depression, stress, and sleep disorders may be observed during the coronavirus disease (COVID-19) pandemic [1]. Following this review, there have been several studies reporting the results of general public surveys. For example, a large-scale study from the United States found that fear was particularly high in areas with many reported cases of COVID-19, and observed a correlation between being socially vulnerable (female, Asian, Hispanic, born abroad, family with children) and fear [2]. Also, longitudinal studies from China and Australia initiated before the SARS-CoV-2 outbreak demonstrated the occurrence of psychological responses owing to the outbreak [3,4]. Further, serum 25-hydroxyvitamin D concentrations, assumed to be related to mental health [5], have also been reported to be decreased in patients with emotional disorders under extended COVID-19 infection [6].

The negative impact of the SARS-CoV-2 outbreak on mental health is gradually becoming clear. Thus, the current challenge for research is the determination of the elements impacting these negative psychological responses. Further, the risk of suicide, which is the worst possible psychological response in a disaster situation, is unclear.

Considering a stress model of psychological response during a disaster suggests that social support and coping style can influence the psychological response level. Studies have shown that social support reduces anxiety and depression amid the SARS-CoV-2 outbreak [7,8]. Negative thinking and avoidant behavior accompanying negative coping have been reported to be associated with depression and psychological distress [9,10].

Although there is limited research about the SARS-CoV-2 outbreak, personality traits may also impact a stress response. A past meta-analysis found a negative association between neuroticism and mental health [11]. As for predictors of psychological distress, cyclothymic, depressive, and anxious temperaments in personality with a need for approval in attachment style were reported as risk factors and confidence and discomfort with closeness in attachment style as protective factors [12]. Further, people with high extraversion experience have been hypothesized with greater psychological stress amid circumstances limiting social interaction, such as the SARS-CoV-2 outbreak.

People cannot live without stressors, the factors that produce mental and physical stress responses. Excessive exposure to stressors can lead to hyper and chronic stress reactions, which in turn can worsen physical and mental health-related outcomes such as physical and mental deterioration, psychological distress, and suicidal ideation. In contrast, appropriate coping can reduce perceived stress and improve physical and mental health. Such an association between stressors, coping, and physical and mental health outcomes have also been reported under the influence of COVID-19 [13,14]. Even under the spread of COVID-19 infection, appropriate coping will likely have a positive effect, both directly through the improvement of physical and mental health-related outcomes and indirectly through the reduction of perceived stress on stressors such as unemployment.

From the aforementioned discourse, it is clear that there is insufficient detailed research on psychological responses to the SARS-CoV-2 outbreak in the general public focusing on the Japanese population. Moreover, many studies from other countries and regions have used adjusted correlations between variables; however, only a few focused on mediated correlations between variables. Thus, this study aimed to investigate both the direct and stressor-mediated impact of demographic data, elements related to COVID-19 infection, personality, social support, and coping on physical and psychological status using structural equation modeling (SEM).

2. Materials and Methods

2.1 Participants

An online survey was administered to the Japanese who were 18 years or older registered with an online outsourcing service provided by Crowd Words, Inc. The responses were received from 1,500 participants between May 26 and May 27, 2020 (viewed by 2,594 individuals, acceptance rate: 57.8%). Only the participants lacking literacy or cognitive function were excluded. The participants were screened based on responses that were carefully examined to identify random or consistently contradictory responses. No responses fulfilling the exclusion criteria were identified, and all data were used for analysis. More detailed information on the basic characteristics of the participants has been reported in our existing short report [15].

2.2 Survey Items

2.2.1 Basic Demographic Information

Participants were inquired about the basic demographic information, including age (multiple choices from under 19 years to 70 years or older); sex (female, male, other); prefecture of residence; the highest level of education completed (middle school graduate, high school graduate, junior college/vocational school/technical school graduate, college graduate, graduate school graduate); marital status (unmarried, divorced/widowed, married [do not live with a partner], married [live with a partner]); ethnicity (Asian, black, multi-ethnic, white, Chinese, Middle Eastern/Arab, other); employment status before the outbreak (student, self-employed/sole proprietorship, operating a company, full-time, part-time, contract worker, housewife/househusband, on leave [childcare leave, sick leave, unemployed]); and annual household income before the outbreak (selected from <18600 USD, 18600 USD to 37200 USD, 37300 USD to 74500 USD, 74600 USD to 111800 USD, 111900 USD to 149000 USD, and ≥149000 USD).

Regarding the SARS-CoV-2 outbreak, participants were enquired about how often they went to their workplace under the state of emergency declaration (almost never, half the week or less, more than half the week, almost every day); amenities in their residence and the surrounding environment (whether they had a garden, balcony, parks, or botanical gardens); the number of preschool-age children in the home; whether they had underlying physical or psychiatric disorders; whether they had been infected with COVID-19 (recovered, recovering, infection suspected, not infected); about contact with infected persons in the past week (had contact, suspected contact, no contact); and extent of voluntary restriction of outside activity (did not leave home at all, did not leave home unless exercising or shopping for food, went out for work in addition to shopping when needed, did not refrain from going out but practiced social distancing, or did not refrain from going out and did not practice social distancing).

Concerning stressors, participants were asked to assess 15 items regarding life events likely to occur under the state of emergency declaration on a four-point scale of “did not happen,” “happened, but was not stressful or difficult,” “was a little stressful or difficult,” or “was very stressful or difficult” (see Table 1 for the list of items). Each item was scored from 0 to 3 points.

Lastly, participants were asked about whether they performed any of the seven intentional behaviors intended to bolster mental health or change the mood to evaluate “coping” (see Table 1 for the list of items).

Table 1 Frequency of life events, stressors, and coping.

2.2.2 Psychological Scales

The ten-item personality inventory [16] was used as a personality index. This scale measures an individual’s personality based on the five-factor model (the Big Five). The Japanese version (TIPI-J) was developed, and its validity was confirmed by Oshio [17]. Participants’ responses to two questions for each of the five factors were rated on a seven-point scale (Extraversion [EXT], Agreeableness [AGR], Conscientiousness [CON], Neuroticism [NEU], Openness [OPE]). Each factor was scored from 0 to 14 points.

A shortened version [18] of the Japanese edition of the Multidimensional Scale of Perceived Social Support [19], comprising of seven items with high factor loadings taken from the original scale, was used as an index of social support. The participants responded to items such as “my family lends a hand to support me mentally when I need it” rated on a seven-point scale. The total score ranged from 7 to 49 points.

The SF-8TM was used as an index of mental and physical health [20]. The Japanese version of the SF-8TM was developed by Fukuhara [21]. A standard physical component summary (PCS) and mental component summary (MCS) with a mean score of 50 and standard deviation (SD) of 10 were calculated based on an algorithm derived from the standard scores of 2,284 Japanese individuals [21]. A higher score indicated better health for both summary scores.

The Kessler (K6) scale was used as an index of psychological distress[22]. The Japanese version of the K6 was developed by Furukawa [23]. Scores on the six-item scale range from 0 to 24 points. A higher score indicates higher psychological distress. The mean ±SD from a community sample of 85,154,382 Japanese individuals aged 15 or older was 3.34 ±3.39 [24].

The Suicide Behaviors Questionnaire-Revised (SBQ) was used as an index of suicidal ideation [25]. This scale measures the level of suicidal ideation and comprises four questions, each assessed on a five-to-seven-point scale. The total score ranges from 3 to 18 points. This scale was translated into Japanese using back-translation.

2.3 Statistical Analysis

All variables used in this analysis are enlisted in Table 2. Categorical variables were converted into binary. The following responses were entered as 1 while any other response was entered as 0. Sex: Female; the highest level of education: junior college graduate; comorbidity: psychiatric outpatient; employment status: full-time employed or unemployed (excluding student); housing facilities: garden or balcony; preschool-age children in the home: 3; having been infected with COVID-19: infection suspected; contact with infected persons: had to contact; the extent of voluntary restriction of outside activity: did not refrain from going out and did not practice social distancing. First, Spearman’s rank correlation coefficient was calculated using IBM SPSS 26, and a two-tailed significance test was performed to explore correlations between variables. The significance level was p < 0.0001. Subsequently, a mediation model was considered SEM using Mplus 8.4. A hypothetical model of the direct and indirect effects mediated by stressors of demographic characteristics, COVID-19-related elements, coping, personality, and social support was created on PCS, MCS, K6, and SBQ, respectively, as objective variables. Paths that did not reach the significance level (p < 0.0001) were temporarily removed after which, the paths deemed necessary based on χ2 value were reincorporated to obtain the optimal model. The standards for model fitting were standardized root mean squared residual (SRMR) ≤ 0.08, the comparative fit index (CFI) ≥ 0.95, and the root mean square error of approximation (RMSEA) ≤ 0.06 [26].

Table 2 Correlation between the variables.

2.4 Ethics

The participants voluntarily cooperated with the survey based on informed consent with written explanations. The research design was approved by the Research Ethics Review Committee of the Practical Psychology Institute, LLC (No. 2020001).

3. Results

A minimum of one response was collected for each of the 47 prefectures of Japan. The participant characteristics are shown in Table 1, Table 3 and Table 4. According to Japan’s February 2020 Labour Force Survey, 51.7% of the population aged 15 years or older are female and 4.5% are self-employed/sole proprietors [27]. Compared to the Japanese workforce population, there were slightly more females and self-employed/sole proprietors among the participants in this study. Further, mean scores for MCS and K6 (43.43 and 6.49, respectively) were less than the standard scores in Japan under ordinary circumstances.

Table 2 shows the correlation coefficients between each variable. Several significant one-to-one relationships were observed between the variables.

Table 3 Characteristics of the study participants.

Table 4 Psychological measures: Descriptive statistics.

Tables 5 and 6 show the results of SEM. AGR (total/indirect b = 0.1, confidence interval [Cl] [99.99%]: 0.01 to 0.18), social support (total/indirect b = 0.03, Cl: 0.01 to 0.06), and psychiatric disorder (total b = –2.69, Cl: –5.32 to –0.07; indirect b = –0.3, Cl: –0.78 to 0.19 ns; direct b = –0.14, Cl: –0.39 to 0.11 ns) had significant total effects on PCS.

Table 5 Unstandardized path coefficients (b) estimated using structural equation modeling.

Table 6 Standardized total effects (β) estimated using the structural equation modeling.