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“Life is not about waiting for the storm to pass, it’s about learning to dance in the rain.”
Vivian Greene

From prolonged school closures for primary and secondary school students, to alternative work arrangements and adverse circumstances such as no pay leave or unemployment for working adults, COVID-19 has seemingly wreaked havoc in the daily lives of people from different backgrounds. Disruption to daily routines is an important factor that causes psychological distress, and is often associated with the development of anxiety and depression.

Researchers from the University of Hong Kong (HKU), including Professor Tatia Lee of Department of Psychology, Dr Winnie Tso and Dr Patrick Ip of Department of Paediatrics & Adolescent Medicine, LKS Faculty of Medicine, in collaboration with Professor Wai-Kai Hou of Department of Psychology, the Education University of Hong Kong (EdUHK) and other institutions, have conducted a series of studies in the past two years on how COVID-19 adversely affect people’s mental health and its association with society.

The findings released in 2022 by Professor Tatia Lee and Dr Wai-Kai Hou’s team discovered that disruption to daily routines can increase the odds of developing conditions such as anxiety and depression.

The research team conducted two representative population-based surveys in two phases of the developing pandemic: when the pandemic was less severe with fewer disruptive public health measures (Survey 1: February 25 to March 19, 2020, N=4,021), and when the pandemic was more severe with strengthened public health measures (Survey 2: April 15 to May 1, 2020, N=2,008). A total of 6,029 participants aged 15 or above in Hong Kong took part in the surveys.

Results showed that the odds for developing anxiety were 14.9% and 14%, and 19.6% and 15.3% for depression in surveys 1 and 2 respectively. The researchers remarked that the percentages of those having depression and anxiety symptoms were relatively high among the population in both surveys, and the increased odds of depression and anxiety symptoms correlate positively with the disruption to daily routines.

During the different stages of the pandemic, more burdens are incurred on the mental health of those whose daily routines are disrupted. Groups such as those under financial pressure, lower education level, single parents, or elderly people leading a relatively lonely life are more prone to developing anxiety and depression under the pandemic. Study results showed that socioeconomic status (SES) and mental health are directly correlated. Financial pressure brought forth by the pandemic has incurred additional burdens on the mental health of the population. For instance, reduction in free or cheap meals made available at schools has led to increased food expenses for low-income families. Individuals with less assets (i.e., low savings, no homeownership) were at greater risks of developing poorer mental health during the pandemic.

Previous studies have found that loneliness is a significant predisposing factor for depressive symptoms. Another study by Professor Lee and Dr Hou examined the association of loneliness with depressive symptoms in adults aged between 18 and 92 years old (N=1,972) during the acute phase of COVID-19 in Hong Kong (February 27 to March 17, 2020). The study found that loneliness is positively correlated with depressive symptoms. The researchers also discovered that rumination, an uncontrollable and recurrent focus on negative thoughts known to underpin depression, intensified when one felt lonely, and its positive association with the intensity of depressive symptoms is stronger among older adults (>65 years old).

The study also found that resilience and regular daily routines will lower the occurrence of probable anxiety. Therefore, developing personal resilience, including the confidence in the ability to change and bounce back from hardships, and sustaining regular daily routines is key to bolster mental health. Those who were more resilient -- defined by their greater ability to adapt to change, bounce back after illness or hardship, and sustain their daily routines -- were less likely to experience anxiety. In addition, more resilient individuals with regular primary routines, particularly among those reporting lower levels of worry, were more strongly associated with lower odds of probable anxiety. These findings underscore the importance of cultivating cognitive and behavioural resilience in buffering against the negative impacts of COVID-19 on our mental health.

Children’s Mental Health
Since February 2020, schools in Hong Kong have received intermittent orders to shut down to fight the spread of COVID-19. While lockdown proved to be a highly successful method of tackling the pandemic, research has found that such efforts have also incurred significant costs to children’s mental health. In particular, a study in 2020 by Dr Tso’s team having surveyed 29,202 families with children, discovered that children were at a greater risk of  having emotional and behavioral difficulties during the pandemic, while stress of their parents also greatly increased. It is worth noting that in comparison with SES, a larger portion of stress was derived from the mental health status of the children and parents, while the stress experienced by single-parent families is noticeably greater than that of families with both parents.

These findings suggest that sharing responsibilities of care among family members is a critical determinant of protection against household stress during the pandemic. Another study by the team in 2022 pointed out that during the intermittent school closure period, the risk of improper treatment of children with special needs had risen, of which those with mental disorder suffer a much higher risk. Special Educational Needs children and their families require comprehensive support in health, social welfare, and education.

While COVID-19 necessitates technology-based learning, studies have shown that the extended use of electronic devices is associated with greater parental stress and increased psychosocial problems in children.

The study by Dr Tso’s team released in 2020 further showed that disruption to daily routines (e.g. irregular sleep schedule, extended electronic device usage) is associated with greater psychosocial problems in both children and adults. The study released by Dr Hou’s team in 2021 found that disruption to different daily routines has a significant correlation to the increased odds of anxiety and depression, both at the start of the pandemic and as it progressed. More specifically, individuals who reported a medium-to-high disruption to primary routines (e.g., sleep and healthy eating) and secondary routines (e.g., socializing and leisure activities) were more likely to experience an array of emotional/stress symptoms -- regardless of incidence rates and the intensity of government-based interventions in Hong Kong.

To this end, the research teams have made the following ten recommendations for children, younger adults, and older adults to help enhance their mental health and overall well-being:

1.   Sustain regular routines where possible, with a particular focus on healthy eating, sleep, socializing, leisure activities, and work/study
2.   Cultivate resilience by building confidence in your ability to change and bounce back from hardships, and through building a positive mindset and practice self-reflection, gratitude, and kindness towards others
3.   Construct cooperative social relationships
4.   Keep in mind that the current limitations are temporary
5.   Rearrange work priorities, and work on goal setting and time management
6.   Avoid making comparisons with others on your achievements, and identify small things in life that makes you happy
7.   Strengthen family bonds, plan for rests, work, and play time to establish plans and expectations
8.   Enable positive parent–child interactions as they can reduce children’s psychosocial problems and parental stress
9.   Avoid extended use of electronic gadgets and ensure sound sleep as it helps improve children’s behaviours and social emotional development
10. Protect children and your family by receiving COVID-19 vaccination

Without a doubt, COVID-19 has brought people unimaginable inconvenience in the past two years. Although prolonged disease-containment measures have effectively curbed the spread of the virus, the disruptions they brought to society have been undeniably detrimental to mental health. From school closures to social gathering restrictions, the pandemic has dramatically limited people's activities at homes. In turn, such containment measures have exacerbated feelings of loneliness and increased the odds of depression and anxiety symptoms in the local population. As studies continue to reveal the consequences of the pandemic, we must learn to protect our mental health. Although it remains unknown when the pandemic will end, there is much we can do to manage and bolster our mental health in the meantime.

References
Hou, W. K., Tong, H., Liang, L., Li, T. W., Liu, H., Ben-Ezra, M., ... & Lee, T. M. (2020). Probable anxiety and components of psychological resilience amid COVID-19: A population-based study. Journal of Affective Disorders, 282, 594-601.

Hou, W. K., Lee, T. M. C., Liang, L., Li, T. W., Liu, H., Ettman, C. K., & Galea, S. (2021). Civil unrest, COVID-19 stressors, anxiety, and depression in the acute phase of the pandemic: a population-based study in Hong Kong. Social Psychiatry and Psychiatric Epidemiology, 1-10.

Hou, W.K., Lee, T. M. C., Liang, L., Li, T. W., Liu, H., Tong, H., … & Goodwin., R. (2021). Psychiatric symptoms and behavioral adjustment during the COVID-19 pandemic: Evidence from two population-representative cohorts. Translational Psychiatry.

Tong, H., Hou, W. K., Liang, L., Li, T. W., Liu, H., & Lee, T. M. (2021). Age-related differences of rumination on the loneliness-depression relationship: Evidence from a population-representative cohort. Innovation in Aging, 5(4).

Tso, W. W., Wong, R. S., Tung, K. T., Rao, N., Fu, K. W., Yam, J. C., ... & Wong, I. C. (2020). Vulnerability and resilience in children during the COVID-19 pandemic. European Child & Adolescent Psychiatry, 1-16.

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Communications and Public Affairs Office, HKU
Ms Melanie Wan (Email: melwkwan@hku.hk)
Ms Rashida Suffiad (Email: rsuffiad@hku.hk)